Facility Evaluation Report

At 9:00am on 07/01/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to address allegations on a separate complaint. Upon screening of care staff, LPA Jeffries discovered that Staff 1 (S1) was not cleared to work at the facility. LPA ran S1 through Guardian, and LIS background checks and did not find S1 on facilities rosters, or by name, date of birth, or social security number in Guardian system. LPA Jeffries requested that S1 leave the facility due to not being a cleared staff. A citation was issued for uncleared staff for the total of the 3 days the staff had been working at the facility. The 3 days of work was verified by interview with S1 and interviews on 07/01/2024 with S2 and S3 during the investigation visit on 07/01/2024.

Exit interview, report read, citation and civil penalty issued, appeal rights and report provided.