Facility Evaluation Report

On December 06, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit and met Administrator, Natalie Marcaida. LPA Mixson introduced herself and explained the purpose of the visit.

LPA Mixson toured the facility, along with Administrator, Natalie Marcaida and made observations pertaining to another matter that CCL was made aware.

There were two staff present and four residents at the time of this case management health and safety visit.

There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson requested and received pertinent documentation. LPA made record reviews pertaining Staff signing another staff name on the MARS. The review of the records revealed staff have not signed another staff’s name. Additionally, LPA made observations pertaining to all resident medication records. There were no observable issues reviewed currently.

LPA appraised Facility staff files. The records reviewed demonstrated there were no documented white outs or cross outs reviewed at this time. The review of the records included the Medication Administration Records (MARS). Staff writing other staffs names was found to be unsupported. There were no documented incidents that could be determined that any staff initials were written without the staff’s permission.