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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247200745
Report Date: 03/25/2026
Date Signed: 03/25/2026 06:04:31 PM

Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NEW BETHANYFACILITY NUMBER:
247200745
ADMINISTRATOR/
DIRECTOR:		ELDAOUCH,BASUNYFACILITY TYPE:
740
ADDRESS:1441 BERKELEY DRIVETELEPHONE:
(209) 827-8933
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY: 76CENSUS: 38DATE:
03/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:DSD Nurse Nicole Lowe CiuffoTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with DSD Nurse Nicole Lowe Ciuffo.

Facility is licensed for 76 residents and has a current census of 38. Nicole stated currently there are no residents on hospice and 1 resident with home health. Home Health Plan was reviewed. Water temperature was checked in 2 different wings in the facility, first bathroom water temperature read at 113.1 degrees Fahrenheit and the second bathroom read at 106.3 degrees Fahrenheit. Fire Extinguishers were serviced March 18, 2026 and is within the safety regulation period. Carbon monoxide detectors were tested and in working order. Facility had the annual inspection for the sprinkler system on February 12, 2026, and passed with no concerns.
Basuny Eldaouch Administrator's Certification expires November 20, 2026. Staff files were reviewed, and not complete at this time. Resident files were reviewed, and some are not complete. First aid kit on site and complete. There is a locked storage are for medications.

LPA inspected the interior and observed the exterior of the facility including the common areas, resident bedrooms, bathrooms, medication storage, and kitchen. Bedrooms are clean, properly furnished, with adequate lighting, and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745
VISIT DATE: 03/25/2026
NARRATIVE
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LPA observed the following deficiencies:
  • Laundry detergent accessible to residents under the sink in a laundry room.
  • Cleaning/disinfectant in unlocked utility closet in activity room.
  • Scissors, hand pruners, and insect killer in unlocked closest in the activity room.
  • Ice machine had build up on the inside and hard water build up on the outside
  • Water dispenser in activity room has hard water build up on dispenser.
  • Current physician reports for residents.
  • Pre-Admission Appraisals for residents.
  • Personal inventory logs for residents.
  • R1's centrally stored medication log which did not have a start date for Tamsulosin 0.4MG & Atorvastatin Calciui/40MG
  • LPA reviewed staff files and some of the following were missing: TB test results, current training, physicals.
  • Training duration for completed training.

Deficiencies observed were cited during today's inspection per California Code of Regulations, Title 22.


LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing by April 6, 2026.

Exit interview conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to DSD Nurse Nicole Lowe Ciuffo.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
Page: 10 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed scissors, hand pruners, and insect killer in unlocked closest in the activity room. LPA observed cleaning/disinfectant in unlocked utility closet in activity room. LPA observed laundry detergent accessible to residents under the sink in a laundry room.
POC Due Date: 03/26/2026
Plan of Correction
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Administrator will in-service staff and items will be placed in secure location. Verification will be sent to the Dept by POC due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed R1's centrally stored medication log which did not have a start date for Tamsulosin 0.4MG & Atorvastatin Calciui/40MG.
POC Due Date: 03/26/2026
Plan of Correction
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Staff corrected log while LPA was at the facility. Administrator will have in-service will all staff regarding centrally stored medication log.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed ice machine to have mildew/build up on the inside and hard water build up on the outside, water dispenser in activity room has hard water build up on dispenser tray.
POC Due Date: 04/06/2026
Plan of Correction
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Administrator will discuss with dept leads and in-service staff. Verificaiton will be sent to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed staff records and 5 staff records did not have the TB test results in the files.
POC Due Date: 04/06/2026
Plan of Correction
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Administrator will go through files and have proper documentation for TB. Verification will be sent to the Dept by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, & record review, the licensee did not comply with the section cited above in 5 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Training documentation does not reflect number of hours conducted on training.
POC Due Date: 04/06/2026
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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Nurse will consult with Administrator on policy. Verification of policy will be sent to the Dept by POC due date.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above in 2 out of 7 resident physician reports do not have a diagnosis listed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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2
3
4
Nurse will follow up with Administrator to have physician reports proper completed. In-service will be conducted with staff. Verification will be sent to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview & record review, the licensee did not comply with the section cited above in 4 out of 7 resident files did not have a current physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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2
3
4
Facility has on site physician who comes weekly. Reports will be updated and verification will be sent to the Dept by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 03/25/2026 06:04 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/25/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a written personal property inventory which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
1
2
3
4
Administrator will in-service staff. Verification of in-service will be sent to the Dept by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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