Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit on June 16, 2022 at 05:30 p.m. to conduct a Case Management (Deficiencies) visit LPA met with Executive Director Sara Mackedsy and explained the purpose of today's visit.

LPA and LPM attended the facility Resident Council Meeting and observed 20 residents openly discuss their complaints and concerns related to the facilities operations.

Based on previous interviews with Administrator Sara Mackedsy during a previous complaint investigation she stated she did mention to Resident 1 "if he continues to file complaints she won't even have a job at the facility anymore." This statement can be interpreted as deterring residents from filing complaints with state licensing.

The following deficiencies are being cited per Title 22 Regulations.

An exit interview was conducted with Administrator Sara Mackedsy and a copy of this report along with appeals rights provided.