Facility Evaluation Report

On 11/17/2023 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate a Case Management visit. LPA Brown was greeted and granted entry by a staff member and Licensee Sue Lal was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee Lal. The investigation consisted of observation, interviews, and a review of pertinent documentation.

On 11/17/2023 at 02:00 PM, LPA Brown toured the facility with Staff #2 (S2) and observed the side gate secured and locked with padlock. LPA Brown informed Licensee Sue Lal that deficiency will be issued as they did not comply with the regulation by locking the side gate/perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate health, safety, and personal rights risk to residents in care.

Moreover, during the tour of the facility on 11/17/2023, LPA Brown observed the half bed rails on Resident #3 (R3) and no written order from R3's physician indicating the need for the postural support maintained in R3 facility record. LPA Brown informed Licensee Lal that deficiency will be issued as this poses potential health, and safety risk to residents in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Licensee Sue Lal.