Facility Evaluation Report

Licensing Program Analyst (LPA) Robert Frank arrived unannounced for a Case Management visit.

The facility is being cited for not having a currently certified Administrator. As this is the second time the facility is being cited for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed.

During today's visit, LPA observed that a magnetic key for a medication cabinet in common area, next to the storage room was unsecured next to the cabinet. LPA has a photograph of the unsecured magnetic key. This deficiency will be cited. As this is the second time the facility is being cited for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Caregiver Nicadao. Signature on form confirms receipt of documents.