Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a complaint investigation when LPA observed the following deficiencies. LPA met with Administrator and explained the purpose of the visit.

When conducting interviews, LPA was informed that R1 has the tendency of eloping from the facility in multiple occasions since admission. LPA was informed law enforcement was contacted in multiple occasions due to the elopement. LPA further explained that incident reports are to be provided to Licensing within seven days of occurrence. Administrator further stated R1 was admitted to the hospital for evaluation, which Licensee then informed hospital that R1's level of care can no longer be managed at the facility and R1 will not return. LPA and Administrator discussed that residents are to be provided a reassessment and a 30 day eviction letter if wished to no longer retain.

When discussing about R2's level of care, LPA was informed that R2 was admitted to the facility with a stage 4 pressure wound, but R2 is no longer at the facility. LPA informed Administrator that facility is not allowed to retain or accept residents with prohibited health conditions without the approval from the Department.

As a result of today's visit, deficiencies observed. Please see LIC 809-D.

Exit interview and a copy of report and appeal rights provided.