Facility Evaluation Report

At approximately 12:05PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Other visit and met with the Manager on Duty Cheyenne Flores, Health Services Director as Administrator was unavailable. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection.

LPA requested and reviewed documents for all employees hired from April 2024 to September 2024. Review of documents showed that facility hired 30 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Medication, care giving for dementia residents, Medication shadowing.

· Financial Solvency – Auditing Dept handling

· Fire clearance concerns (Fire Department involvement) - POC has been cleared

· Insufficient care and supervision & medication errors as previous multiple citations – (facility is currently under investigation)

· Licensing fees (late fees not paid 2 nd notice sent) –LPA informed of outstanding and overdue Licensing fees.

During visit, LPA was informed that Executive Director, Rajvir Sandhu, will be overseeing the community as the new Administrator. LPA requested Administrator documents to be submitted to Community Care Licensing (CCL) by 09/23/2024.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.