Facility Evaluation Report

On 4/2/2024, LPA Johnson arrived and met with the Administrator, who assisted LPA with the visit to determine if the plan of correction has been completed for the citation given on 1/31/2024.

LPA reviewed the requirements of the Fire Marshal from the visit dated 1/2/2024. The required information has not been met and the facility does not have a generator that meets the fire clearance requirement. This was confirmed by the facilities' records and the fire prevention inspector's report. The facility is working with an outside agency to obtain a temporary generator that will be in place within 5 business days. The temporary generator will be used until the required generator is installed and functional. The facility currently has a fire clearance permit that expires 10/2024.

The original plan of correction date has passed. The facility had a plan to address the original citation given on 1/31/2024, however, additional information from the Fire Marshal requires that the facility put in place a level 1 generator since power failure would result in loss of life or serious injury.

The facility will submit a plan to the department when the temporary generator will be in place by the close of business on 4/9/2024. This is an extension of the plan for the citation given on 1/31/2024.