Non-compliance follow-up·November 8, 2023

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Lacy Berry, Administrator, and explained the purpose of the visit. During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed Care Plan Reviews to last be conducted on 10/12/2023. LPA observed recent quarterly training to be conducted on 8/22 Fall Reduction, 9/26 Changes in Condition, 10/18 Dementia Care, along with printouts of PowerPoint presentation. LPA observed documentation of the last quarterly visit conducted by Solar Senior Living representative, Jonathan Harris, to be on August 8, 2023. LPA informed Administrator LPA will discuss with Licensing Program Managers if quarterly visits with Solar Senior Living and Ciminocare are to be conducted in tangent, as LPA observed the current quarterly visit to be offsetting. LPA obtained a copy of Solar Senior Living and Ciminocare Quarterly Visits log, and statements from 07/27/2022 to 08/08/2023. LPA observed no quarterly audit has been conducted by Allen Flores Consulting Group since LPA's last quarterly visit conducted on 8/23/2023 as the most recent audit was completed on 8/17/2023. LPA is requesting a copy of facility's LIC 309 ADMINISTRATIVE ORGANIZATION. Additionally, LPA is requesting a copy of the most recent quarterly audit conducted by Allen Flores Consulting Group on 8/17/2023. All documents are to be submitted to LPA by close of business 11/15/2023. If by 11/15/2023, no new audit has been completed by Allen Flores Consulting Group, LPA is requesting a copy of the new audit once available. Exit interview conducted. Copy of report provided to Administrator.