Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted a Plan of Correction (POC) visit regarding a deficiency that was cited on 7/16/2025. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Cathy Allen.

On 7/16/25 LPA cited a deficiency for a resident sustaining multiple falls in care due to the facility not adhering to said resident's care plan. The POC due date was set for 7/25/25, and LPA did not receive documents by the agreed upon date nor did the facility communicate to LPA prior to the POC due date for additional time.

As the Licensee failed to correct the deficiency and notify LPA by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. A Civil Penalty of $100.00 a day has been assessed from 7/26/25 to 8/4/25 for a total of $1,000.00.

Licensee submitted proof of correction to LPA during today's visit to the facility and so the POC has been cleared.

An exit interview was conducted with Executive Director Allen to whom a copy of this report, the POC Clearance letter, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.