Facility Evaluation Report

On 01/18/2024 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Lena Rush to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 01/09/2024, Licensing Program Analyst (LPA) Melody Brown requested a copy of the facility’s Personnel Report (LIC500). On 01/12/2024, LPA Brown requested Licensee/Administrator Rush an updated copy of the facility’s form LIC500 and Licensee/Administrator Rush verbalized understanding. LPA Brown received the updated form LIC500 via email and LPA Brown reviewed document received and cross reference Guardian database and observed that Staff #6 (S6), Staff #8 (S8), Staff #9 (S9), Staff #10 (S10) and Staff #12 (S12) have their background clearance, but they were not associated to the facility as their criminal background clearance were not transferred to the facility. Moreover, LPA Brown observed Staff #7 (S7) does not have criminal background clearance. Staff interview and records review indicated S6 started working at the facility on 04/11/2023, S7 on 07/20/2023, S8 on 12/23/2020, S9 on 12/04/2021, S10 on 09/20/2019 and S12 on 07/19/2023. During the facility visit on 01/18/2024, LPA Brown informed Licensee/Administrator Lena Rush that deficiencies will be issued and Civil Penalties were assessed during the facility visit with the amount of $500.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected for failure to obtain criminal record clearance for S7 and for not transferring S6, S8, S9, S10 and S12 criminal background clearance to the facility.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Lena Rush.