101212(d) · 101212 Reporting Requirements (d) Upon the occurrence, during the operation ... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. Facility agrees to provide a statement of understanding of reporting requirement regulations and will submit the LIC 624 for the incident dated 4.22.25

,facility did not submit the UIR within the required reporting time frame Karren Starks NAME OF LICENSING PROGRAM MANAGER: Patsy Plancarte NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2026 I acknowledge receipt of this form and understand my appeal rights as explained and received.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

101216(g)(2) · Personnel Requirements (2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following

Deficient Practice Statement Based on record review,one out of six files did not have a completed Health Screening, which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 03/12/2026