Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit regarding deficiencies that LPA observed. LPA met with Interim Administrator and explained the purpose of the visit.

Today's visit, LPA continued a complaint investigation and discovered that staff (S1) has been working at the facility since September 2024 when S1 did not have a criminal record exemption. LPA was informed that this matter was brought to Executive Director's attention at the beginning of S1's employment and S1 did not know it was a concern as S1 continued to be scheduled for shifts. S1 has since been removed from schedule until exemption is granted.

Additionally, based on the investigation regarding resident (R1)'s medication error which was previously cited on August 15, 2025, LPA was informed that staff (S2) had informed Executive Director and Health and Wellness Director that R1's medication is running out and did not have an active primary care physician on file to fill the medications. S2 was informed that Executive Director will resolve the issue; however, LPA was informed this matter was not resolved until August 7, 2025, after R1 had missed all routine medications for approximately 30 days.

As a result of the information obtained, deficiencies cited. Please see LIC 809-D.

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