Routine inspection·March 6, 2024

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator and Licensee arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensee discussed magnet release for fire door, process to request a secured perimeter waiver, and securing items in the facility that could pose a hazard to residents. Resident records reviewed. Licensee to include Pre-appraisals, care plans and PRN authorization for all residents. Staff files reviewed. Filles to be better organized and all training documented in files. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and copy of report left at the facility.