Follow-up·January 5, 2024

On 1/5/23 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA met with the two staff members at the facility. LPA spoke with Ester from Admin over the phone, staff member K. McKinny assisted LPA at the facility during the visit. LPA spoke with Ester regarding an incident report that was submitted 12/14/23 to LPA's email account regarding R1's incident that occurred 11/12/23. Ester stated it was a typo and the incident occurred 12/12/23, LPA informed Ester to submit a revised incident report for R1. Facility provided a revised incident report with the correct date and activity log for the date the incident occurred by 1/9/24. An incident report was submitted for R2 which resulted in a change of condition. Ester stated the incident report was originally sent to LPA on 12/21/23, and the follow-up incident report was sent 1/3/24. LPA was able to confirm. LPA was not able to locate S2's current LIC602A, reappraisal, health care plan and verification of staff training for R2. The facility will provide the information to LPA by 1/9/24. The resident actively log indicates R2 was discharged and back at the facility as of 1/2/24. At this time no deficiencies were cited Exit interview was conducted with Ester over the phone and a copy of this report LIC809 was provided to Caregiver K. McKinny who will be signing the report.