Facility Evaluation Report

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director/ Administrator .

During the investigation of complaint number 59-AS-20251226110029, LPA found, through records and statements, that R6 used a catheter and that the catheter changes and flushing were done by a family member who was not a licensed professional. Title 22 regulation 87623 Indwelling Urinary Catheter- (a)(1)(A)and (B) states: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. (B) A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders. R6 has since moved from the community.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided