Facility Evaluation Report

Licensing Program Analyst (LPA) Sommer Hayes and Licensing Program Manager (LPM), Stephen Richardson arrived unannounced to conduct a Case Management visit 07/09/25 at 08:30am to follow up on a recent death report from 07/01/2025. LPA and LPM were met by caregivers, S1 and S2. Beatrice Clark was contacted and arrived at 9:45am and LPA and LPM stated the purpose of today’s visit. The facility is licensed for a capacity of 6 residents. There are currently 5 residents.

The purpose of this visit is to follow up on the death of Resident. (R1) occurred on 07/01/25. The Department received a death report on 07/07/25 at 6:05pm.

Per review of the death report, the cause of death is unknown. Additionally, R1 was receiving hospice care services beginning sometime in June 2025.

Through documentation review of staff and resident files, LPA and LPM learned there have been changes to facility documentation from the Administrator who is in the process of a change of ownership and have not been licensed yet. Some resident and staff files are not kept at the facility based on an interview with the facility administrator.

LPM and LPA observed an admission agreement for R2 from Providential Senior Care, which is not a licensed facility but in the application process with Centralized Application Bureau (CAB). Additionally, LPA and LPM observed that the facility does not document routine medication administration on a Medication Administration Record (MAR) and confirmed that through interview with S1 medication is not being recorded when dispensed, but visually confirmed.