Facility Evaluation Report
Capacity6
Census5
Date signed10/25/2024 04:45:59 PM
The purpose of this visit is to amend the complaint report for complaint number 26-AS-20230314081243 delivered on 09/18/2024.
Based on a complaint investigation, when resident R1 sustained an injury to his/her left eye, the facility did not submit an incident report LIC624 to community licensing office within 7 days after the occurrence of the incident. See LIC809-D.
An exit interview was conducted with Administrator (ADM) for review and signature of this report. A copy of this report was provided to ADM. Appeal rights was provided to ADM.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction