Eskaton Gold River Lodge.

Allegation: Staff not providing food to residents in memory care when requested. LPA conducted interviews, record reviews, and observations as noted above. Based on observations and record reviews, it was revealed that residents in memory care received food items during mealtimes as well as through special requests of residents. LPA observed various residents in memory care served timely and in accordance with diet orders. Additionally, interviews conducted did not reveal any corroborated statements or evidence supporting the allegation noted above. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff not responding to memory care resident needs as required. LPA conducted interviews, record reviews, and observations as noted above. LPA observed residents in memory care attended to timely including toileting needs, redirection as necessary, and general supervision of residents. Additional observations in memory care revealed timely assisting of residents in under ten minutes. Interviews conducted revealed that staff are attending to resident needs timely and adequately, with no further corroborated evidence to support the allegation noted above. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.

presented in the emergency room (ER) with an “altered mental status, fatigue and generalized weakness…” R1 was diagnosed with sepsis. Interviews with staff noted that R1 would refuse treatment. Facility documentation notes that staff checked on R1 when they observed a change in condition. It was unclear if R1 developing sepsis was due to staff not obtaining timely medical attention or due to R1’s refusal for treatment. Due to these inconsistencies, there was not a preponderance of evidence to substantiate that hospitalization was a result of lack of care and supervision. The allegation was UNSUBSTANTIATED and no deficiencies were cited. Exit interview was conducted with Executive Director and a copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 well, experiencing weakness, confusion and runny nose. On 11/06/2024, at 6:30 PM, R1 was seen by paramedic due to weakness and back pain. R1 refused to go to the ER. On 11/07/2024 at 12:29 PM the home health agency providing services to R1 called 911 due to R1’s weakness and confusion. Staff became aware of R1 having a change in condition on 11/5/2024. Staff interviews and facility notes do not show that staff contacted R1’s primary care provider (PCP) when the change of condition was noted.  Based on documentation and information provided through interviews there was a preponderance of evidence to show that the facility did not properly assess resident and did not report the change in condition to PCP as required and therefore this allegation is SUBSTANTIATED. It was alleged that “Facility did not allow resident to come back to the facility after being hospitalized.”  Per facility documentation dated 11/18/2024 at 3:18PM, the facility was notified that R1 would be discharged back to Eskaton Gold River the following day on 11/19/2024.  On 11/19/2024, the Resident Care Coordinator (RCC) for the facility called the hospital requesting that R1 be transferred to a skilled nursing facility for rehabilitation, stating that R1 has to be able to bare weight otherwise R1 is not appropriate for the facility.  The facility should have allowed R1 to return home as the hospital stated that R1 needed a 2-person assist, and not any mechanical interventions/accommodations.  The facility refused.  The facility should have allowed R1 to return home, re-assessed R1's needs, and updated R1's care plan. If after a thorough assessment, it was determined that the facility could not continue to meet R1's needs, the responsible party should have been notified.  An updated care plan should have been created and a draft of a 30-day eviction letter stating that the resident required a higher level of care, along with supporting documentation, should have been submitted to Community Care Licensing for review.  The facility should have also assisted the resident and their responsible party in locating an appropriate placement, as required. Based on documentation and information provided through interviews there was a preponderance of evidence to show that the "Facility did not allow resident to come back to the facility after being hospitalized," and therefore this allegation is SUBSTANTIATED. Exit interview was conducted with AD Alfredo Cruz and a copy of this report was provided along with APPEAL RIGHTS.

LPA learned from interviews that staff members (S3 and S4) were reviewing video footage to ensure that all staff were wearing their masks and utilizing their PPE as directed. Both S3 and S4 stated that they saw 2 employees not wearing their masks as directed. S3 informed this LPA that those employees were coached and counseled on the importance of following infection control protocols. In addition, when this LPA conducted her visit on 11/14/24, she also observed a staff member (S5) on the first floor not wearing a mask. The standard for the preponderance of evidence has been met and the Department finds the allegation, "Staff are not following infection control protocols," to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Alfredo Cruz.

LPA received a document from a staff member (S4) dated 2/22/24. It confirmed that a resident at Eskaton Village tested positive for Covid. It also confirmed that this information was communicated from Eskaton Village to Eskaton Gold River prior to the transfer of residents. The Memory Care Coordinator at Eskaton Gold River stated that she was not informed that a resident had tested positive for Covid at the Eskaton Village facility and therefore had not taken any special precautions.  Additional care staff were not brought in, however another Enrichment Assistant was added to help the newcomers engage with the community and to decrease any anxiety they might have felt over their sudden change in environment. During a review of the Coronavirus/COVID-19 Preparedness and Response Plan, (the Plan ) dated 09/14/2022 by Eskaton Gold River Lodge, page 17 stated that, "New move-ins should be tested at the time of move-in.  This can be done with a PCR or rapid antigen test." This was not done.  3 out of 3 staff interviewed stated that there was no mention of these residents potentially being exposed to COVID-19 and they were not screened, isolated, or masked. In an interview with S4, this LPA learned that the newcomers were seated together for meals in the communal dining room with the other residents in care.  This was done in order to assist them with acclimating to their new surroundings. According to a review of records, on 02/27/24 at 4:30 PM, one of the Eskaton residents (R1) complained of a sore throat and an inability to swallow. R1's temperature was taken and was recorded as 97.4 degrees Fahrenheit . Hospice was notified.  At 2:00 PM, when the responsible party (F1) was visiting R1, R1 complained of a sore throat again.  F1 requested that R1 be tested for COVID. The med tech on duty denied the request and responded that wasn't policy and that they only tested when symptoms were present.  F1 replied that there were symptoms, i.e. the sore throat.  When the med tech refused to test R1, F1 requested a test kit so that they could test R1.  The med tech provided the test kit.  R1 test positive for COVID. Hospice was notified and the resident was then isolated to prevent the spread of COVID. Upon further review of the Plan, this LPA found that the staff at the facility did not follow their mitigation protocols.  Per this plan, on page 5 it stated, for confirmed Covid - 19 cases, "Reported illnesses have ranged from mild symptoms to severe illness and death. Symptoms may appear 2-14 days after exposure to 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the virus. People with these symptoms or combinations of these symptoms may have Covid- 19: Fever or chills Cough Shortness of breath Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea" On page 40 , number 6 of this plan, it also stated, " Test residents and staff who had known exposure to the individual. Additional testing should be done based on guidance from the health department and the level of exposure." According to interviews with S2, this was not done; at a minimum, the residents who transferred from Eskaton Village should have all been tested as they previously lived in the same facility and had been grouped together in communal areas after arriving. On page 58 of this document it went on to state precautions in memory care specifically: 8. " Suspected or Confirmed cases of COVID-19 - If it is necessary to isolate a resident in memory care due to suspected or known COVID -19, consider these steps in addition to normal COVID-19 policies: As it may be challenging to restrict residents to their rooms, implement universal use of eye protection and N95 or other respirators (or facemasks if respirators are not available) for all personnel when on the unit to address potential for encountering a wandering resident who might have Covid-19. Moving residents with confirmed COVID-19 to a designated COVID-19 care unit can help to decrease the exposure risk of residents and staff. Additionally, at the time a resident with COVID-19 or asymptomatic infection has been identified, other residents and personnel on the unit may have already been exposed or infected, and additional testing may be needed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 d. If due to cognitive impairments it is not possible to isolate the resident, it may be necessary to treat the entire memory care area/unit as isolated. This would include not allowing staff to work in other areas of the community, and implementing droplet/contact precautions throughout the memory care area/unit. " When this LPA conducted interviews,  5 out of 5 respondents stated that staff were not required to wear masks while working in the memory care communal areas, only upon entering the room of a resident who had been confirmed COVID positive. S2, S6, and F1 all stated that R1 would wander out of their room looking for their friend and had the opportunity to come in contact with unmasked residents and staff. This LPA learned that Eskaton Gold River did not follow its own Covid-19 Preparedness and Response Plan on multiple occasions.  Residents from Eskaton Village were potentially exposed and were not tested upon move-in.  R1 was not tested for COVID-19 symptoms even though they were complaining of a sore throat. The other residents who had been in close proximity to R1 were not immediately tested for COVID-19, as directed by the Plan .  R1 exhibited wandering behavior when the attempt was made to isolate them.  Masks were not required for staff in the common areas and both residents and staff were potentially exposed to COVID when R1 left their room. A total of 6 residents were reported to have tested positive for COVID-19. in the February/ March time frame of this complaint. The standard for the preponderance of evidence has been met and the allegation, "Staff did not follow protocols to prevent the spread of illness," has been SUBSTANTIATED. Regarding: Staff did not assist resident in a timely manner. R1 should have been tested for COVID-19 upon move-in. They were not.  R1 should have been tested for COVID-19 when they complained of a sore throat. According to interviews both S2 and F1 confirmed that R1's temperature was checked and because it was normal, R1 was told that they were not exhibiting COVID 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 symptoms and would not be tested. According to the facility's own Plan, a sore throat is a COVID symptom and testing should have been done. The standard for the preponderance of evidence has been met and the allegation, "Staff did not assist resident in a timely manner, has been SUBSTANTIATED. According to the California Code of Regulations, Title 22, all deficiencies are listed on the LIC 9099 D page.  A copy of this report was provided along with the APPEAL RIGHTS and an exit interview was conducted with the Administrator, Neal Torres.

party stated that food was being served at improper temperatures. Through interviews and observation, this LPA learned that there was a fan located above the kitchen hood where food would be placed for staff to carry out to the residents. This fan kept the kitchen and the staff form getting too warm, but it would also cool the food down quickly. This was one reason why residents were receiving food that was not at its proper serving temperature. This LPA also learned that some of the staff at the time did not know how to pace the meals. The staff might bring out the soup, salad, and entree at the same time. By the time the resident finished their first course, the entree would be cold. In addition to these reasons, this LPA also learned that there had been issues with kitchen equipment during the time frame of this complaint. The top oven broke and therefore staff had to cook in batches and use a hot box to keep meals warm. At one point, the hot box broke too. Since the time of the complaint, the facility has had the oven repaired and purchased a new hot box. The Kitchen Manager has implemented a new role, Culinary Lead, to assist with training staff. Food is not put up under the hood for delivery until just before it is to be delivered and the staff has been trained to pace the delivery of each course. The standard for the preponderance of evidence has been met and the department finds this allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, the citation may be found on the LIC 9099 D page. A copy of this report was provided, along with APPEAL RIGHTS. Exit interview. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the facility floors were clean," this LPA has toured this facility 6 times. This LPA has completed a walkthrough of the facility on the following dates: 03/29/24, 06/10/24, 06/11/24, 06/24/24, 07/10/24, and 07/17/24. The LPA did not observe the kitchen or facility floors to be unclean. The standard for the preponderance of evidence has not been met and the department finds these two allegations to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. According to the California Code of Regulations, Title 22, this LPA did not observe or cite any deficiencies during today's visit. A copy of this report was provided along with APPEAL RIGHTS. Exit Interview.

This LPA was told Memory Care was staffed with the following: the AM shift had 3 care staff and 1 med tech plus the Memory Care Coordinator (MCC). The PM shift was staffed with 2 care staff plus 1 floater and a med tech. The NOC shift was staffed by 1 care staff and a med tech. As part of this investigation, this LPA interviewed 9 staff members. 2 of the 9 confirmed that staff were not consistently transferring residents properly. This LPA learned that care staff were using the Hoyer lift by themselves (1 person instead of a 2 person assist). Operation of a Hoyer lift requires 2 people. The standard for the preponderance of evidence has been met and the department finds the allegation, "Staff are transferring resident(s) in an unsafe manner." to be substantiated. This deficiency was cited on the LIC 9099D page. No other deficiencies were observed or cited during today's visit. A copy of this report was provided along with Appeal Rights. Exit interview.

On 6/11/24, Licensing Program Analyst (LPA) Kimberly Viarella arrived at this facility to continue the annual inspection. LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Neal Torres and a brief meeting followed. LPA provided materials to assist with future file reviews. LPA then returned to reviewing staff files to ensure proper background clearances, health checks and training were all in compliance. LPA reviewed 4 resident files. All were complete and up-to date at the present time. LPA observed that the DFA's certificate (# 6032067740) expires on 01/02/2025 and was in compliance at the time of the visit. LPA reviewed 3 staff files and found that they were missing annual training. In 2 of 3 files, the files did not contain the required number of annual hours of training and the training did not include the name and credentials of the trainer or the regulations that the training pertained to. 2 out of 3 were Medication Assistants but the training logged and presented did not include annual medication training. 1 of the 3 staff files did not meet the annual training requirements and had repeated course content listed. The DFA produced a binder with in-services that were conducted and signature sheets of attendees, however, these did not meet regulation requirements. The DFA also produced an excel spreadsheet to demonstrate that training was implemented, however, the log sheet did not include the duration of the trainings, the trainer, or specific content. It also did not include the topics required as mandatory for annual training. LPA provided technical assistance and handouts which referred to the regulation requirements in order to assist the DFA in establishing a more efficient system for implementing and tracking required trainings. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As part of this annual inspection the LPA visited 2 of the 4 medication rooms at this facility, one in memory care and the main one in assisted living. LPA inspected med carts, checked for expired medications and reviewed dosing, storage, destruction, and PRN procedures with the Medication Assistants in each area. LPA tested the response time for staff on two occasions in different parts of the facility. LPA activated the pull cord in the restroom of a resident in one wing of the facility. Care staff arrived in 13 minutes and 39 seconds. After visiting the medication room, the LPA observed a resident in another wing of the building activate their pendant and care staff arrived in 1 minute and 3 seconds. LPA concluded the inspection of the building by walking the perimeter with the DFA. There were no outbuildings or water features present. The exterior of the facility and the grounds surrounding it were in good repair at the present time. According to California Code of Regulations, Title 22, the following deficiencies were observed during this inspection. They were cited on the LIC 809D page. Civil penalties were also assessed for the missing background check and lack of transfer associations. A copy of this report was provided along with Appeal Rights. Exit interview.

On 06/10/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with DFA / Executive Director, Neal Torres, and a brief interview followed. The tour began in the kitchen. LPA inspected pantry as well as the chest freezer adjacent to the prep area and then walk-in refrigerator and freezer. LPA pulled a sample of items from each and found none to be expired. LPA observed opened packages of chicken tenders and mozzarella sticks were not properly repackaged or dated in the chest freezer. LPA observed 3 opened lidless containers of ice cream and an undated, unboxed, leftover cake. LPA took pictures for reference. LPA observed that there were no food items stored on the floor, prep stations were clear of debris and organized. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The fire extinguisher was last inspected on 08/14/23 by Fire Code Safety Equipment. The hood was last inspected on 10/20/23 by Braun and Son's. The tour continued into Memory Care. LPA inspected the 2 kitchenettes in this area. LPA opened all drawers and cabinets to ensure that there were no sharp objects or toxic chemicals present. LPA also inspected the refrigerator and found food items in plastic containers that were not labeled or dated. LPA also observed a large container of peanut butter that had an order date, but no expiration date or date when the container was first opened. LPA visited a sample of resident rooms in Assisted Living, Memory Care and Pre-Memory Care. All rooms had 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the required furniture, furnishings and lighting to be in compliance at the present time. All resident bathrooms in assisted living had grab bars, non-slip surfaces in the showers and trash cans. Bathrooms in memory care had locked cabinets for toiletries or other restricted items. LPA measured hot water to ensure it was between 105 and 120 degrees Fahrenheit. Hot water measured 113.1 and was in compliance at the time. LPA began file reviews but due to time constraints, this LPA will have to return at a later date to complete this annual inspection.

Although the facility had an agreement in place with the family and resident for no room overnight checks for the resident to not disturb the resident’s dog, the department has identified the facility did not meet their own requirements of two hour room checks that should have been conducted per facility’s plan of operation. Resident left the facility at approximately 7:30pm and there were no checks on the resident after that time. Per the family and facility there was an agreement for no checks from 10:00pm to 6:00am. As a result, no staff checked on the resident to ensure their health safety or whereabouts for the resident from the time period of 7:30pm to 10:00pm which exceeds the time limit identified in the facilities plan of operation. The department has also obtained a copy of the coroner’s report regarding the death of former resident. The coroner’s determination of death for the resident is hypothermia. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Questionable Death is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22 and an immediate civil penalty has been issued. The circumstances of this complaint are being evaluated for additional civil penalties. Exit interview was conducted with the facility Administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

This report is being amended to include required information that was omitted by LPA in order to meet department standards of required information including who LPA met with during the inspection. Licensing Program Analyst (LPA) Kevin Gould made an unannounced Case Management inspection to the Eskaton Gold River Lodge (RCFE) on 11/16/23 at 9:00am to address concerns observed during a complaint investigation. LPA met with Lynn Perena and together discussed the department’s concerns and observations. Based on statements obtained during the department’s investigation of an assigned complaint the department has determined there is a preponderance of evidence to support multiple staff members including outside caregivers discussed or expressed concerns with a decline in resident’s cognitive abilities, short term memory and orientation of time and place. Three care providers who interacted with R1 on a regular basis provided statements to the department observing confusion and cognitive decline of R1. Two of the three interviewed described confusion related to facility orientation. Two staff members interviewed provided statements that R1’s mental decline was a topic of discussion in “stand up” meetings among staff members. The latest Physician report dated October 2022 did not include any mention of dementia or MCI. Other documentation observed post physicians report include: additional confusion, wandering and looking for 5 dogs (resident only had one at the facility). All documentation and statements were given prior to the resident care meeting with authorized representatives where memory care placement was discussed but no evaluation was conducted to ensure resident’s needs were met by facility staff. Department interviews and review of surveillance footage with morning shift staff present on the date Resident was discovered outside the building, observed resident’s dog in the parking lot unattended at approximately 4:58am. Facility staff interview indicate facility staff were not notified by arriving staff member until 5:20am and resident was discovered outside the building at approximately 5:23am. The department has concluded the staff members present did not display competency in the required duties for care and supervision of resident as resident’s animal was observed unsupervised and resident was not checked on immediately to ensure the resident’s health and safety. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per California Code of Regulations, Title 22, the following deficiencies are cited. Exit interview conducted and a copy of this report and appeal rights were left at the facility.

The department could not corroborate the allegations regarding the cleanliness of R1's bathroom. LPA Gould made an unannounced inspection on 7/6/23 and conducted a tour of the facility to ensure health and safety of residents and observed the resident's bedroom and bathroom to be clean and well maintained. Interviews with housekeepers at the facility did not reveal any pattern or documentation of the bathroom being dirty. The department could not obtain any evidence to support the facility not being clean, sanitary and in an odorless condition. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of Physical Plant is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Although there were several directives for reduced care and supervision prior to the meeting, the department has concluded the facility made no changes or alterations to the supervision agreement once it was determined the resident had increased medical needs requiring care and supervision. The department has determined the facility should have developed a plan for a higher level of care and if the resident’s needs could not be met, served the resident with an eviction notice due to needing a higher level of care. Additionally, The department has determined based on record review the facility did follow all reporting requirements in terms of reporting suspected abuse. Facility did write and submit a report of suspected elder abuse to the department and law enforcement. However, the department has determined that the facility did not report the suspected abuse in a timely manner that meet the requirements of Title 22 regulations and the Welfare Institutions Code (WIC) that requires suspected elder abuse with serious bodily injury to be reported to law enforcement within two hours of knowledge of the suspected abuse and per documentation received law enforcement was not notified until 7/7/23. This is also corroborated by family reports to law enforcement with no other pending report prior to their report given to police on or before 7/5/23. Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.

On 7/12/23 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address a self reported medication error. LPA met with Administrator Neal Torres to discuss the reported incident. Administrator confirmed that there was a medication error regarding the administration of a resident's medication 6/25/23. Facility contacted the resident's physician to ensure the safety of the resident. Facility has already conducted in services training with the staff member and has resumed several days of shadowing during medication pass. Facility continues to evaluate electronic medication administration records (EMARs) for incorporation into the facility's medication administration process. LPA and Administrator discussed additional steps the facility can take to eliminate additional medication administration errors. Per California Code of Regulations, Title 22, the following deficiency is cited. Due to a previous citation in the past 12 months, a civil penalty is issued.

On 6/20/23 at 9:30am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address a self reported medication error. LPA met with Administrator Neal Torres to discuss the reported incident. Administrator confirmed that there was a medication error regarding the administration of a resident's insulin on 6/9/23. LPA met with the resident who could not recall the medication error and reported feeling no negative effects from the error. Facility contacted the resident's physician and poison control to ensure the safety of the resident. Facility has already conducted in services training with the staff member and has resumed several days of shadowing during medication pass. Facility continues to make adjustments and clarity for insulin administration and continues to evaluate electronic medication administration records (EMARs) for incorporation into the facility's medication administration process. LPA, Administrator and Resident Care Coordinator discussed additional steps the facility can take to eliminate additional medication administration errors. LPA and administrator reviewed the Health and Safety Code for employees assisting residents with self administered medications and reviewed the Department medications guide and a copy was provided to the administrator for distribution. Per California Code of Regulations, Title 22, the following deficiency is cited. Due to a previous citation in the past 12 months, a civil penalty is issued. An exit interview was conducted, a copy of this report and appeal rights were left at the facility.