Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a report sent to CCL on 12/12/23. LPA was greeted and met by Staff Danielle Baysinger at the front door. LPA introduced self and stated purpose of the visit. LPA phone called the Licensee/Administrator Roy Baysinger to inform him about the unannounced case management visit.

On 12/13/23, LPA Echeverria was notified about discrepancies found by IRC on the clients medication and P&I records.

During today's visit, LPA did a health and safety check, toured the facility, review medication and P&I records. During the tour of the facility, LPA observed the following: window screens missing on the kitchen dining window, living room window, staff bedroom window, and client's bedroom window; a locked side gate on the outside/right side of the facility with an obstructing path on the outside/left side gate next to the garage door; and an unlocked closet where medication and knives are stored. LPA also observed discrepancies while reviewing records. Accessible client records found in the living room, the emergency disaster plan was not updated, the administrator's certificate was expired during 09/2021-09/2023, P&I client records were not accurate and were missing receipts, MARS did not match actual medication provided to clients, and missing incident reports for the medication and P&I discrepancies.

Deficiencies were issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and then provided to staff, Danielle Baysinger.