Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to check on the health and safety of residents in care. LPA identified herself and was granted access to the facility by Nyna Drayden, caregiver. LPA met with caregiver Drayden and discussed the purpose of the visit. Administrator Shanta Haines later arrived at the facility and joined the visit.

The visit was initiated due to a self reported incident that involved client #1 . LPA toured the facility, and requested and obtained relevant documents maintained by the facility . The Administrator was notified that this visit may require further follow-up. No immediate health and/or safety concerns were observed during today’s visit.

An exit interview was conducted with Administrator Haines. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to the facility at the conclusion of the visit. The signature below confirms receipt of these documents.