Facility Evaluation Report

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 1:45 p.m. The LPA was greeted by staff and informed them of the reason for the visit. This is an annual continuation, which began on 06/19/2023.

RECORDS: The LPA began a records review at 2:00 p.m., the LPA began the records review by reviewing staff associations and compared the Licensing Facility Personnel Report Summary dated 6/19/2023 and 8/1/2023 against the facilities most recent LIC 500 dated 3/22/2023 and Guardian. The LPA identified 7 staff who are in need of further record review.

Due to time constraints, the LPA will return at a later date to complete the inspection.