Facility Evaluation Report

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate complaint #18-AS-20221028150306. During today's inspection, LPA Colvin observed that while staff (S1) does have background clearance from Department of Social Services, S1 has not been associated to this facility and needs to have their clearance transferred to reflect employment at this location. Additionally, the form LPA Colvin was provided to show that S1's clearance was requested to be transferred to this location is not the correct form to do so, and is not dated or signed. Through interviews LPA Colvin confirmed that S1 has been working at this location for almost a month. Since S1's clearance has not been transferred to this location and S1 has been working at the facility for approximately one month, L PA Colvin will be citing a deficiency and issuing civil penalties in the maximum amount if $500 ($100 per day x 5 days).

While LPA Colvin was typing the report, Corporate Office for the Licensee sent the Administrator a picture of Guardian to show S1's clearance at the facility. LPA Colvin looked at the picture and observed the association date to be 11/3/22, which is today's date. LPA Colvin informed the Administrator of this and that while it's good that S1 is now associated to the facility (and LPA Colvin did check earlier prior to Corporate's call and S1 was not on the facility roster) that S1 still worked at the facility for a month without clearance transfer, and the deficiency will stand.

Due to observations made by LPA Colvin, the facility was cited and civil penalties are being issued in the amount of $500. An exited interview was conducted where a copy this report, LIC809D, LIC421BG, and appeal rights were provided to Assistant Administrator Victor Hayes.