Facility Evaluation Report

On 11/19/24 at 10;15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding regulatory compliance. LPA met with Licensee William Puckett and explained the purpose of the visit. LPA reviewed documentation related to complaint #27-AS-20240805090404 and # 27-AS-20240823100640. LPA also conducted interviews with Administrator. Based on interviews and record reviews, it was determined that on 4-5-24, a facility staff member received a restraining order to maintain distance from a resident1 (R1) living at the facility. This event was not reported to licensing department. Additionally, during July 2024, R2 engaged in an absence without leave (AWOL) and insufficient staffing was a contributing factor. It was determined that a scheduled one-on-one staff member was late for her shift and Administrator did not ensure an appropriate staffing solution at that time.

As a result of today’s case management, citation is issued under Title 22, Division 6 and noted on 809D. An exit interview was conducted with Licensee and a copy of this report was provided to Licensee.