Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Hood met with Administrator, Chris Butts, to conduct a case management visit.

During inspection conducted on 10/28/2021, LPA requested all incident reports regarding resident (R1). LPA obtained what Unusual Incident Reports (SIRs) the Administrator supplied.

On 5/18/2022, the Department received 2 SIRs regarding R1 dated 9/8/2021 and 9/29/2021. Due to facility not supplying the Department with all requested documents during inspection conducted on 10/28/2021, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87506(a) regarding complete resident records. Deficiencies are listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.