Facility Evaluation Report

On 10-23-2025 at 2:58pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a previous report generated from an outside compliance agency. LPA met with Administrator Danica Morrison and explained the purpose of the visit. During this visit, LPA met with Administrator and reviewed agency inspection report dated 5-21-2025. Report was given to Licensee on 10-17-2025. Based on review, it was determined that on 5-21-25, various areas of care and supervision, documentation, and physical plant were out of compliance. Such areas included but not limited to: (1) A junction box for the front gate was observed on the ground with exposed wiring, the gravel covering the driveway for the PVC piping (for remote gate) was unlevel and exposed the PVC piping along the entryway to the home in two areas creating a trip and fall hazard, the pleated blinds covering the living room window were torn in several locations, a large area of peeling and chipping paint (approximately 24 inches in length) existed along the right side of the door frame around the door that exits to the backyard, the left arm of the turquoise chair in the living room had a large tear (approximately six inches long by one inch wide), and the Medication Administration Record (MAR) was reviewed, and a medication error was identified.

The MAR demonstrated that on 05/10/25, medications were passed to resident1 (R1). However, the MAR also identified that three medications were not provided to the R1 on the morning of 05/10/25. Additional findings included but not limited to: Monthly regional center meeting not scheduled monthly, regional center meetings identified various individual behavior support plans containing inconsistencies with graphs, charts, and reporting data, various fidelity checks not completed for January – February 2025, inaccurate information was identified on multiple incident reports, {Cont. on 809C}