Inspection Report Summary
The most recent inspection on January 22, 2025, identified deficiencies related to client safety during transportation and drop-off, specifically involving failure to ensure physical transfer of custody and signatures. Earlier inspections also cited issues with timely notification of changes in client condition, medication administration errors, and documentation deficiencies. Substantiated complaint investigations found violations concerning client rights, safety, and communication with physicians. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows recurring themes around client safety and care coordination, with no clear pattern of improvement or worsening over time.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Lidia Ayala | Executive Director | Personnel contacted during the inspection |
| Sheryl Bilyard | SALSA | Personnel contacted during the inspection |
| Megan Edson-Sawyer | Nurse Consultant | Survey Team Leader and report submitter |
| Elizabeth Heiney | Supervisor | Supervisor of the survey team |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the initial inspection letter and contact for questions |
| Sheryl Bilyard | Resident Care Director | Signed the plan of correction on behalf of the facility |
| Lidia Ayala | Executive Director | Recipient of the inspection letter |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lidia Ayala | Executive Director | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lidia Ayala | Executive Director | Personnel contacted during the inspection. |
| Debbie Bartosiewicz | Regional Nurse | Personnel contacted during the inspection. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the notice and contact for plan of correction |
| Sheryl Bilyard | Resident Care Director | Responsible staff member for ensuring compliance with plan of correction and presenting nurse re-education |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Cheryl Davis | Public Health Services Manager | Author of the desk audit letter and contact for plan of correction |
| Holly Francia Kiss | Supervisor of Assisted Living Service Agency (SALSA) | Responsible staff member for ensuring compliance with plan of correction |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the initial notice letter for the investigation. |
| Michael J Smith | Nurse Consultant | Recipient of the plan of correction submission. |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Michael J. Smith | RN, Nurse Consultant | FLIS staff conducting the inspection. |
| Barbara Davis | Ex. Director | Personnel contacted during the inspection. |
| Mary Leone | RN, SALSA | Personnel contacted during the inspection. |
| Joan D. Mowyer | Supervisor | Granted approval for issuance of license. |
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