Raksha 13 Care Home

FACILITY EVALUATION REPORT

COMPLAINT INVESTIGATION REPORT

This report documents a virtual meeting held on August 19, 2025, to review the plan of corrections for previous violations dated August 8, 2025. The meeting covered fire clearance violations and addressed questions and clarifications with all necessary parties present.

The case management visit on 08/08/25 focused on fire watch implementation and compliance. The primary deficiency cited is the failure to obtain the required fire clearance approval for bedridden residents, which constitutes an immediate health and safety risk. The facility must address this critical deficiency by the specified due date.

The facility underwent a required Annual Inspection on May 6, 2025. The general observations noted adequate conditions regarding safety, sanitation, and supplies. The primary deficiency found was the need to update the Emergency Disaster Plan (LIC610D).

The facility underwent a required Annual Inspection on 05/03/2024. The physical inspection noted several positive aspects, such as adequate temperature control, sufficient supplies, and clear passageways. However, one deficiency was cited regarding the administrator's certification documentation, which requires immediate attention to prevent potential risk to residents.

The facility underwent a required Annual Inspection on 06/05/2023. While general areas like passageways, lighting, and basic supplies were observed to be adequate, several administrative and documentation deficiencies were noted. Specifically, the administrator's certificate is nearing expiration, and the Emergency Disaster Plan and administrator certifications require immediate updates.

This report details a complaint investigation conducted on 02/02/2023 regarding allegations such as questionable death, pressure injuries, food quantity/quality, resident rotation, and pests. All allegations investigated were found to be unsubstantiated by the licensing evaluator.