Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/7/23 to conduct a Continued Annual Inspection. LPAs met with Executive Director and explained the purpose of the visit.

LPA completed Resident file reviews during this visit.

Inspection found three(3) of six(6 residents with physician's reports out of date.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Exit interview conducted and copy of report and appeal rights left at the facility.