Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by Administrator Edward Alicdan Jr. LPA is conducting Non-compliance in conjunction with annual inspection. All deficiencies cited will be cited on the annual inspection, except for deficiency cited for inadequate staffing, citation issued on this report.

On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as:

· Administrator Duties and Plan of Operation

· Follow through with responding to and participating with the Technical Support Program

· Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.

· Ensuring personal rights of residents in care and ensuring resident needs are met.