Facility Evaluation Report

Licensing Program Manager, Kimberley Mota, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst’s (LPA’s) Dominic Tobola, Farhaan Sarangi, Araceli Canela met with Licensee/Administrator, Sukhjit Sandhu for the purpose of reviewing issues during a Non-Compliance Conference.

The purpose of this office meeting is to discuss Non-Compliance plan (NCC) which will be extended due to items of concerns about the operation of the facility not being resolved. Parties present during this meeting agreed to extend the Non-compliance plan until 8/13/2024. Original NCC plan went into effect 8/13/21. The Regional Office will re-review progress made on Non-Compliance Plan of one year prior to its expiration date. Areas of improvement have been identified regarding reporting requirements and retaining residents with pressure injuries. Areas of compliance not limited to below were discussed:

· Fire clearance concerns (Fire Department involvement)

No deficiencies cited during the Non-Compliance Conference.