Follow-up on corrections·September 17, 2025

Citations

2 citations recorded^*CCLD

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

  87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by:Based on observation and interview the licensee fail to provide the require proof that the administrator on duty is meeting the qualifications of hours spent at the facility. This violation poses a potential health and safety risk to all residents in care.

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• 87211(a)(1)(D)Type B

  87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident...,or unexplained absence of any resident. This requirement was not met as evidence by:Based on LPA's interviews conducted and record reviews, the Licensee failed to report incident (R1's) A/C system not working 09/01/25. This violation poses a potential health and safety risk to all residents in care.