Facility Evaluation Report

A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities continued substantiated noncompliance since the last NCC conducted on 05/05/25 . Present at today’s NCC were Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Stephen Richardson , Licensing Program Analysts (LPA) Kesha Lewis, Sommer Hayes Wendy Martinez Assist. Administrator and Licensee Arvin Davis Leah Davis. The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.

Citations from licensure to 05/05/25 - six (6) A type citations in areas of Inspection Authority (repeated) , Basic services and Client Records, Acceptance and Retention Limitations and Reporting Requirements. One (1) B type citations in the past 3 years in the area of Administrator - Qualifications and Duties.

Citations since NCC Meeting on 05/05/25 include 6 additional Type A citations in the areas of Acceptance and Retention, Incidental Medical and Dental and Fire Safety. Additional Type B citations in the areas of Buildings and Grounds and Incidental Medical and Dental

Issues discussed related to the above include :

1. Inspection Authority -A plan to ensure Resident and staff records resident records will be available for review at the facility.- the process of reviewing records is timely

2. Plans of Correction submitted timely – ongoing issue

3. Acceptance/Retention and Compatibility (related to IDDM individuals 602 states cannot administer, staff interview and observations is staff are testing blood sugar and administering insulin)

6. Presence of Administrator – since the NCC the Administrator has not been present upon arrival. Additionally, the Administrator reports staffing shortages which cause him to provide care during the overnight shift. Several discussions including on the prior NCC that his role as a caregiver needs to be separate from his role as an Administrator which is responsible for the day to day oversight of the facility.

7. Unpaid Civil penalties totaling $20,100 – Agreement reached on 09/10/25 for repayment of $2,010 per month for 10 months. Additional CPs issued on or after 09/10/25 shall be paid within 30 days of invoicing.

NEW FTB Suspension – proof was provided that taxes were paid for the prior years. 2024 remains unpaid proof of payment will be sent to the department by 9/19/2025.