Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a POC visit and met with Administrator (ADM) Trevor Christiansen. The purpose of this visit is to follow up on deficiencies issued during a Case Management visit on 5/20/2025. LPA stated the purpose of the visit. No clients were present during visit. ADM stated all clients had left for the day.

On 5/20/2025, LPA Tarin conducted a Case Management visit regarding 8 Special Incident Reports (SIRs) and 2 SOC 341s submitted to the Department on 5/20/2025. LPA observed that the 8 SIRs and 2 SOC 341's for Clients C1-C5 were not submitted to the Department within 7 days. The SIRs and SOC341s had a date range from 4/25/2024 to 4/23/2025. Two deficiencies were issued and the Plan of Correction (POC) was developed with the ADM. The ADM stated they will obtain additional training for Title 22 regulation reporting requirements and additional training for administrator responsibilities. The ADM submitted the two POCs by the due date 5/21/2025.

LPA observed ADM training certification completed on 5/27/2025 and additional administrator training scheduled for June 2025.

LPA Tarin cleared the deficiencies cited on 5/20/2025 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit.

No deficiencies were cited during todays visit. An exit interview was conducted with ADM Trevor Christiansen and a copy of this report was provided..