Facility Evaluation Report

On 06/15/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct as Plan of Correction (POC) visit. LPA Pascua and Valerio were greeted by staff member, Andrea Rush and asked to call the Facility Designated Administrator, Julian Hawes to let him know that CCL was present at this time. Shortly after, LPA Pascua spoke to FDA Hawes via telephone and explained the purpose of the visit. LPA Pascua was informed that FDA Hawes could not make the visit and and asked LPAs to continue the visit with SM Rush. Current Census was 4

The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 06/02/2023 from a prior complaint visit conducted on 06/01/2023.

As of the date of this visit, 06/15/2023, the department has received an incomplete POC. The POC stated that the facility will provide a statement of correction as well as no less than 1 hour of training to be provided to all staff. Information that needed to be submitted must include, all attendees, trainers, and information that was discussed. A POC was provided to the department via fax on 06/12/2023 that included 1 hour of training, staff in attendance, and information discussed. The POC provided did not include a statement of correction from the facility.

Based on the information gathered, a Technical Assistance (TA) is being provided for Reporting Requirements.

An exit interview was conducted and a copy of this report was provided to the facility via email and an electronic email read receipt confirms receiving these documents.