Facility Evaluation Report

During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility to conduct an inspection. During this inspection, LPA Colvin observed the following issues which needed to be addressed:

Staff Not Associated to Facility: LPA Colvin observed that 1 of 3 staff present at the facility (S1) are not currently associated to the facility, though S1 does have fingerprint clearance with the Department. LPA Colvin reviewed documents for S1's file at the facility and did observe a fingerprint clearance transfer request for S1 for this facility, though for some reason the transfer was not completed. LPA Colvin is issuing a Technical Assistance Advisory Note to document that the transfer was not completed, and that the Licensee needs to follow up with either resubmitting a transfer request or initiating the transfer himself on the Guardian website. LPA Colvin is not issuing a deficiency at this time as Title 22 Regulations simply state that a transfer must be requested, which the Licensee has evidence that they have done, despite it not being successfully completed.

Incident Reports: LPA Colvin observed that no incident reports have been recorded with Licensing since the facility opened in 2021. LPA Colvin observed copies of incident reports at the facility, so LPA Colvin inquired as to how they were being submitted. Licensee/Administrator Christian Court stated that he would either email them to his LPA (who no longer is with Adult and Senior Care) or he would drop them off at the Licensing office. LPA Colvin advised Licensee to either fax in the reports and retain a confirmation page for his records, or if he wants to continue to drop them off at the Licensing office, to request a copy of the report after it has been time stamped, to show that it was successfully submitted. LPA Colvin is issuing a Technical Assistance Advisory Note instead of a deficiency regarding not submitting incident reports to Licensing as there is evidence (completed incident reports in file) to suggest that the Licensee has submitted incident reports, though none have been logged as received.

An exit interview was conducted where a copy of this report and LIC9102ANs were provided to Licensee/Administrator Christian Court.