Facility Evaluation Report

Licensing Program Analysts (LPAs) LaVette Farlow and Edith Conchas arrived at the facility to conduct a case management visit for deficiencies observed during complaint visit for control number 56-AS-20250603100246.

LPAs observed, Licensee Caroline Armstrong, did not have chemicals locked and secured and inaccessible to residents in care.

LPA's observed during the tour that residents medication was found unlocked and not secured in the following areas; pantry, kitchen cabinets and in the garage in several boxes and bags in plain view and exposed as well as in the refrigerator.

LPA's observed sharps in the food pantry unlocked and not secured and accessible to residents.

LPA's after doing a records review of 3 residents, LPA's observed 3 out of 3 residents files were incomplete. They were missing signatures on the admissions agreement, physicians report, Needs and service plan, Emergency contact sheets , MARs, Preplacement appraisal information, personal rights, and Telecommunication device notification form.

LPA's observed licensee did not have updated LIC 500. The current staff personnel files were incomplete and missing the following documents; Health screening report, TB clearance, Personal Record, Personnel report, Criminal record, verification of training, statement acknowledging requirement to report suspected abuse of a dependent adult or elder. ***CONTINUED LIC809C***