■■■••••■•••m■••■•••110.,

1411111PLE CONSTRDCRON

BURIKNG B. Nem

(XV DATE 8111TVEY CCAERETE:D

Can 1r2010

06/29/2010 14: 05 2026' ? 4 CAPITAL CARE PAGE 04

PRINTS): 08t22/20t0 FORM APPROVED

SIREET ADDRESS, city. STATE, ZIP CODE

2828 itARTPORD MEET, SE StiA9i0NGTO(4, MO

NAME OF PROVIDER OR BUFFUER

CAPITAL CARE

PREFIX TAG

PROVIDER'S PtAN OP CORAECliON (EACH GonREcnve AC WOULD BE

CROSS-INIFERENCED TO TIONTI-CE APPROPRIATE

oc

OW ID PROM

TAO

SIADAARY gTAMIENT OF DEFICIENCIES (EACH CIEFIGERCY =ST BE PRECEDED BY Fth.l.

REGULATORY OR ESC IDENTIFYING th7ORIARTICRB

ORl COUPLETE

PATE

100OI INITIAL COMMENTS

A ra-ficansure survey was conducted on 6/11 /201 0. A random sample of three residents was selected from a resident population of four mates and two femaies wilts varying cognitive and adaptive disabritties. The foxiings of the survey were based on observations, staff MU:views, as was as a review of the resident and administrativo records, inducting the unusual Incident reports.

ofie 350214 MEAL SERVICE / DIMNG AREAS

Each GHURP shall train staff in the stows preparation and serving of food, the cleaning and care of equipment, and food preparation in Order to maintain sanitary conditions at el times.

This Statute is not met as evidenced by. Based on obserwiton and staff interview, the facility failed to enact and enforce the necessary measures to ensure the proper cam of cooking and serving equipment tot all residents ronieirng tit the /reality

The finding includes.

During the emeranmentel inspection an 64112010, at 7:17p.m., the interior nen-stick surface of SIIVerel puts was observed to be In poor =Mon, worn and/or rusting. The facility ' s Residential Coordinator (RC) was interviewed on 6/1112010, at 7:18 p.m., and he Indicated he won id have the worn pots thrown cat and replaced. There was no evidence presented at the time of survey to substantiate that staff had been effectively traced to care for Itny of the eating and cooking equipment as recturnid by this Section_

tk I \S\

GOVERNMENT OF THE DISTRICT OF COLU IA DEPARTMENT OF HEALTH

HEALTH REGULATION ADMINISTRATIO 825 wormi CANTOL ST.. N.E., 2ND FLOO

WASHINGTON, D.C. 20(102

Tete

3502.14 All old pots have been tbrown, and a new set of pots purchased_ Every month, the home manager will do check of all kitchen utensils, and any worn or rusted pots and pans are replaced. All staff have been trained on

proper use and care of kitchen utensils, and reporting to home manager when equipment is rusted.

6/20/10

1000

1068

rat Repletion AtniFite:1

tABORATORY OIRECIDR'S OR PRONRDERfaupPUER RpoRESE.C11)ATTVES RICRA111R6 • 6 tirt Melt

one

7 ciliD seaessaison fart f ate STATE FOTO

06/29/2010 14: Lib 2026; /45 CAPITAL CARE 1 PAGE 05

PRINTED: 0&22/2010 FORM APPROVED

STATEMENT OF oETICIENCEs Ala) PLAN OF C.ORREc nom

co) pRovvarsuppuEmx/A EDEMTIPICATION wow

HPD124W 4 STREET ADDRESS,

po) miaTiPLE A Etta LD2a;

W B. M

CDUsTRuCTION QC3) DATE SURVEY compiLETEo

03/1112010 CITY. STATE. Z1P CODE NAME OF PROIAGER OR SUPPLER

2920 HARTFORD MEET, SE CAPITAL CARE WARNDISTOK cc sae 4;x4) 0 %BMW"( STATEMOIT OF DEFIDIENCLES io PROW:1MS PLAN OF CORRECTION 1 pes) pRERx (FAQ, DEMO= atisia BE PRECEDED BY FULL PREFBC (EACH CORRECTNFE ACTON MO tap BE coupLEsE

TAG REGULATORY OR LSC DENTIFyiNG INFORMATION) TAG CROSS-REFERENCS) TO THE APPROPRIATE DEricni.cy)

DATF

1090 Continued From page 1

_ @ @

1

1090 3504.1 HOUSEKEEPING

The interior end exterior of each GEDARP snail be Maintained In a safe. clean, orderly, at and sanitary manner and be free of accurnulatIorts of 'tit, rubbish, and obtectionable odors.

This Statute Is riot Met as evidenced Sy: , Based on observtion and staff interview, the B a batty failed to enstre integrity cf the physical environment to ensure the health and safety of Its

3504.1 1. Maintenance has been given a list of all

maintenance needs, and will complete all residenb& [Residents 01, CZ 03,194, 1115 and Ce] repairs by 7/5/10

The Endings include: On et112010, at appnoximately 6:45 p the hollowing deficiencies were observed:

2. The Vent in Resident # 2's has been cleaned.

3. The dresser drawer has been repaired. 1. The wall near Resident 02' a bed wed damaged (ie scrape martat, diSOottations. etc).

2. The vent in Resident 02 ' s bedroom MOS

4. The hole in Resident # 4's room has been rePaired-

coveted wan dust. 5. The refrigerator thermometer has been 3. The dresser drawer In Resident 04 ' s replaced, and the temperature reads 38

bedroom was broken and not abta to shut degrees Fahrenheit.

Prayer*. 6_ The Freezer thermometer has been 4. The wall behind the door b Resident 04 ' s replaced, and it now reads 30 degrees badman was damaged_ A small about lite Fahrenheit size of th.4 door harldie WES observed. In the future, the home manager will do a

monthly environmental check and submit all 5. The thermometer In the refrigerator read 60 repair needs to the maintenance department_ dagreaS Fahrenheit The QMRP will provide oversight to ensure 6. The thermometer In the deep treezer read 50 degrees Faturalheit.

that checks are done, and repairs completed timely. 7/5/10.

- - Mailah Rcipitaboa Adrtion STATE FORM CUIttnallon cl`=A 2 dB

POWDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE

CROSSAEFERE)cCED TO THE AppRopRim camords010

coLEPLEre DATE POEM

TAG

=WAR! sracresarr OF DEFICSEXaEs (EACH DEFICIENCY MUST BE PROM= BY FULL

Ram:LAMM csu,sc cnENTTY0fG INFoRMATION) Cu/ PREFOC

TAO

Health Reakilation AistrnInistretion STAllatniT OF DEFICIENCLTS AND PLAN OF CORRECTION

NACE OF PROVIDER OR SUPPLIER

CAPITAL. CARE

A BUILDING

ETREET ADDRESS. PTY. STATE. ZIP OWE

seee HARTFORD STEEL 8E teASKINtiM, DC 20320

MN DATE SURVEY comPLErEo

01/1112040

p(1 ) pRovtozTUSUPPUMMLA oc2) MULTIPLE CONSTRUGRON IDENTIF1CAMON NU:UM

a vatc, RFD12,0074

1 092 Continued From page 2 1 092 3504.3 HOUSEKEEPING

Each GHDARP shall be free of insects, rodents and vermin.

This Statute is not met es evidenced by: Based tut obsetvabon and staff INIOrVietV, the testy fend to ensure an insect free envbonment 133 EMsure t e heal % and safety for air of six of its residents. [Residents 01, 02, 03, 04, 06, and 00]

The flitting includert

During the envirorenerdel bisection on W11i2010, at 7:05 p.m., several ants were observed crawEng over the kitchen counters, Cabinets and also In the tbeadbox. Intends*, with the Residential Coordinator (RC) on the same day at 7.08 p.m. revealed, he would have the extenninator rettrn to the home to address the ants. The tacility fated to ensure tnsect free ernAronmant as required by this socket.

0981 3504.7 HOUSEKEEPING

No poisonous or hazardous &gent shin Ira item in a Coed preparation. storage or sonobg area.

This Statute is not mat as evidenced by Based on observation and staff ar ^terirew, the featy failed to enact arid enfarCe the necessary measures to ensure that poisonous; ander hazardous agents are not stored or kept in a food preparation erwircirwnent OdtchanY The Mang includes:

During the erivirdntriental inspection on

1 092 1 092

1 098

3504.3 Pest control Inspections are done quarterly. The pest control company has been contacted to exterminate ants in the home. The home manager will ensure through daily walk through, and monthly environmental checks that as soon as pests are noted, the pest control company will be requested to take care of the problem.

620/10

3504.7 All cleaning agents have been rein° ved from under the sink. All staff have been mserviced about storage of chemicals. Home managcr will do daily walk through in the home to ensure that chemicals are not stored in a locked cabinet

620/10

06/29/2010 14:05 2026. 745 CAPITAL_ CARE • PAGE 06

PRINTED: 0812212910 FORDA APPROVED

AdriOrAratczn STATE FORM' Mist i ccsdi=±5an st=.4 3 018

06/29/2010 14:05 2026 745 CAPITAL CARE . PAGE 07

FRIN1ED: 082212010 FORS t APPROVED

Health Reoulotion gilministraiion STATECENT OF DEFIES AND PLAN OF CORRECT:ON

NAVE OF MINDER OR SUPPLIER

CAPITAL CARE

pa) FROWDEP/SUPFUERcUA IDENTTrATION NUISOR:R

KF0124974

CC9 MI-11FM CONSTRUCTION A BUILIONG o. wENG

DM DATE sURVEY comptETED

OSH 1/2fft 0 sneerrAcoriess, cm. STATE. 7:8, MOE

2020 HARTFORD SnEzT, BE VASKAGTOP4, DC 20929

0 FREE(

TAG

0,4) iMT1--SXAfltiARY STATEeciiiT or DEAciENciES PREF1x (EACH DalCiENcy WJST BE PRECEDED BY FULL

TAG REGuATORY OR LSC IDENTIFY[NG INFORIdATION)

pRov0Eres PLAN OF CORRECTION VAC11 CORREc ME ACTION mom' SE

CROSSAEFERENCED TO TNE APPROPRIATE DE FICDS4C11

COUPLEW DATE

1 098

1135

1209

.11■••••■

Continued From page 3 6/11/20I 0, at 7:19 p.m., dewing agents Were found being stored in the cabinet below the kitchen sink. Interview with the (tidily • s Residential Coordinator (RC) on &I 12010, at 7:20 p.m.; revealed he Would have the staff retri0V8 the Olaaning aprds from the !sleben and store them in their locked storage area

11351 3505.5 FIRE SAFETY

Each GHPARP shall conduct simulated tire drills in order to test the effectiveness of the plan at least four (4) times a year fir each shtft.

This Statute is not met as evidenced by Based on staff interview and record reviestr, the Group Home for the Mentally Retarded Persons (GliftlftP) failed to ensure a fire drill was conducted on each Blatt to ensure the heath and safety of Its residents. [Rosidents 01, 02, 03, 04, 05 and 081

The finding Includes:

Interview with the taceitys Residential Connittator (RC) on 8/11/2010. at appreurintetely 3:30 pin., reverted the GHIVIRP functioned wet four working skits for shift The westrdey shifts covered 11-9:00 am., and 3-11:00 p.m. Outing the weekends, the shifts run from 11-9:00 am.. and 9-11:00 p.m., There was no evidence any Ora drab were Poing conducted on the weekend shifts. Further interview with the RC confirmed the mlisseig dais and he indict:fed he wouid retrain daft on the requiternents.

12031 3500.3 PERSONNEL POLICIES

3505.5 A schedule for all fire drills has been established for all shifts. Home manger will ensure that drills are completed on all shifts every three months.

6/30/10.

•......■■••■■■••• •••

1 098

IiefrOl STATE FORm elg3 assail tram atart ct444 4 of 8

06/29/2010 14:05 2026 :745 CAPITAL CARE PAGE 08

PRINTED: 081222010 FORM APPROVE)

GCZ MULTIPLE CONSTRUCTION A. autLEING 8. IN8co

STATEMENT OF DEFICOICIES AND PLAN OF CORRECTION

OCI) PROVIDERfStwntETVCITA FDENTIFICATION new

liF11124074

(X8) DATE SURVEY COMPLETED

OfV11/21110 PANE OF PROVIDER OR SUPPLIER

CAPITAL CARE

51REET ADORESS, CITY. STATE, ZIP COO& 2820 HARTFORD MET, SE WAIR10410;3. DC 20020

m PREFIX

TAG

81NiVARY STATMENT OF DEFORMS FAQ' DEFICIENCY TicUST BE PROD BY Futt

REGULATORY OR LSC IDENTIFY= IrPORMATION)

pRoVICIERS PLAN OF CORRECTION (EACN connecnvEakCTION 818NAJD BE

CROSSREFERENCEI) TO TM APPROPRIATE OEFTmENcr

CIO) IO PREFIm

TAG

1 203 Cent hued From page 4 Eacit supervisor erten discuss the contents of job descriptions With each employee at the beginning ernceoyment and at least annmay thereafew.

ThIS Staear Is not met as evidenced by Based on staff interviow and record review. the group home for the mentally retarded parson (GHAIRP) Wad to provide ati staff with a review of their written job descriptions as required by this section for seven (7) out of sixteen (16) Currently employed staff. [Staffitlt, C3, 05, 08 and 091

The finding Includes:

Interview with the Gt-fiViRP ' s Qualified ikilental Retardation Professional (QMRP) end the Residential Coordinator (RC) an 6/11/2010, at sipprceirrietaly 5;45 p.m., confirmed seven of the sixteen staff currently employed by the OriMRP were not provided the opportunity to review and discuss the job description with manegernent.

The GH1VIRP fated to secure evidence that all stuff were afforded the opporttmity to review their job doscripbon as required by this section.

1 208 3509.0 PERSOKNI9.. POLICIES

Each employee, prior to employment and annuely thareatter, shall ormtda a PtlYelcian codification that a health invent:ay has been Performed and that the employee' a health status *fluid reiow hint or her to perform the reetired duties.

This Statute is not met as evidenced by Based on staff line/view znd record review, the

Sts icaa RecpActtan Acnbearction STATE FORM

1 203

1 208

3509.6 Staff who do not have valid health certificates have been informed to update their health status by 7/10/10. The Human Resources Department will conduct quarterly audit of personnel records to ensure that all staff are in compliance with health regulations.

7/10/10

assel cccfnuLlori eltratt 5 call

06/29/2010 14: 05 2026, 745

CAPITAL CARE , PAGE 09

PRINTED: C8/22/2010 FORSU APPROVFO

Health &TATEltaarr OF DIEFICIENVOI ANn ruvi IV, (=MEQUON

pm pRovngtosuppuettut InzsTIFICATiON NLOMER

KFD12-0074

PQ) ID.12.11Fth A MUNRO

vie*

CONSTRUCTION (X9) DATE SURVEY CO

Can li2010 CITY,

DC 20020

MAKE OP PROMER OR SUPPLIER [ STIBrirADDRESS. 2020 HARTFORD CAPITAL CARE INANCXOTOR.

CIVET, STATE, ZrP GOOF

SE

041)10 PREFIX

TAG

sunlAin• STATEMENT OF DEFAME/0ES (EACII DEFICagICY MUST BE PRECEDED UY Fes.

REGULATORY OR LSC =MINING alreisitATIOIB

0 PREFIX

TAG

PROVIDE'S KM of CORRECTION (Fiat CORR:GINE ACTION SHOULD BE

CRO8S.FEREIENCED TO THE APPROPRIATE DEPPENCY)

Cowmen DATE

1208

1227

Contfasied From page 5

i group he for the men retarded person (GHMRP) failed to ensure all staff receivod zU annual health iiwaniory as required by this

1 section for three (3) out of sixteen (10) currently employed staff. (Staffs 05, trot and 015)

! The raiding includes:

Interview with the Gi1PARP ' s Qtiagned Ikarstal Retardation Prolamin:1g (talk') and the Residential Coordinator (RC) on 8111/2010, at

1 aPProximeb* 4:45 Pan., confinned three of sbdaen staff did not have a vatiticunent health cartifecaba 2nd/or heeith inventory on Me.,

1 The (31194FtP failed to secure evidence thet all staff had secured the plops, end riaccierauy health screening as required by this section.

351 O. 5(c1) STAFF TRAINING

Each training program shell include, but not be finsled to, the f °Cooing:

(d)EmeMency procedures including first ail carchoptitmortsvy restisoiltdion (OPR), the Hebnbch maneuver, disaster pima and lire evacuation plans;

This Statute is not met es evidenced by: Based on staff interview and record review, the group home for the mentally retarded persons (Gt114117P) failed to provide .14*m04eh6t fottr (4) out of abdeen (16) staff received training in the

i of first aid and carchopulmonary resuscitation (CPR).

The finding includes:

t 206

I 227

3510.5(d) All staff that have not been trained in CPR and First Aid have been scheduled to obtain their certification. This will be completed by 7/15/10. The HR department will conduct quarterly audits to ensure compliance by all staff of training needs.

7/15/10

STATE FORM t=0 osJ81 1

N cordinusOcn duet 8 of 8

06/29/2010 14: 05 2026, ,745

CAPITAL. CARE .L PAGE 10

PRINTED: 00(22/2010 FORM APPROVED

STANNatT OF ofifICENCE:3 Amy PLAN OF CORRECTION

(xi) piwymusUPPUERCUA FOENT1RCATION Ruzatat

HFD12-4074

co ELAMPLE A. allaznAG

WI s. NG

COMSTRUcTON P13) nAlE suRYEY CoePt.ETED

tleilltZ010 NAME OF PROVLDER OR SUPPLIER

CAPITAL CARE STREET ACCRESM alY. STATE. LIP WOE 29 HARTFORD SLEET, veASHIRCTCW, DC MOO

0491171 =MARY STATEMENT OF DEFICOCES ppEnx (EACH DEFICIENCY MUST BE PRECEDED BY FULL

TAG REGULATORY OR LSO AM3MPRNO 91FORMATIOA) 1

to P'REFIN

TAG

PROVIIXERS Pukm OF CORRECTION OUCH camel-NE ACT)on SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

PTO coodetere DATE

I 227

13751

! Cortlinued From page 8 irdeiviaw watt the facility • s Residential Coon tin' ator (RC) and mord review on 6/11/2010 at apprtvdrnately 3:45 p.m, revealed for out of sixteen personnel records reviak* ved did not relied the staff was certified to perform either CPR or first aid. The GKEIRP ° s governing bo Idled b ensure all employed Staff recelvad training In the arua of CPR and first eld.

3519.8 FAERGENCIES Each Gt.414FtP shall docurnent each emergency and enter the foitow-up actions into the resident ° s permanent record, which shall be trade areitable for revlew by authorized intrividuels

Pia Statute is not mat as evidemed by. Based On staff Interview and record rewire% the group home for the mentality retarded persons (GHIVIRP) faitad to ensure all fattow-up actions ware recorded after emergent care was pnMded for a reSident The finding Includes

The facility failed to ensure the docurnardetion of ggl Ibaceia-up actions as SydanOmi balevi.

Review of the unusual incident reports on eel lama, at 10:35 am., revealed no investigation or any other foldaction was detain:anted lit Residento2, Resident 03, ReSident 04 or Resident 08 ' s records to address the emergent arse they received as identified WOW:

1. 4/8/2010, Resident 02 fen at the home, sustrined a cut on her forehead and was taken to the ER for assessment and treatment 2. 512512010, Resident tk3 was taken to the ER

1 727

1 375

-

3519.6 I. Incident investigator will follow up with

Resident #2's. incident and provide recommendations as needed.

2. Resident # 2's incident with the G-tube has been resolved, however, investigator will provide a summary of investigation, and recommendations for follow up.

3. Investigator will provide investigation summary on resident #4's ER visit for lethargy,

4. Investigation summary and recommendations will be provided on Resident #6's ER visit for excessive emesis.

Capital care has completed training of two more investigators. In the future, all incidents will be investigated in a timely manner and recommendations made for follow up. The Incident management committee will provide oversight to ensure that incidents are investigated timely, and summaries placed on file.

715110

Heath Rpsibtion STATE FORM 054511 coatiuskon aloe! 7 Of 6

06/29/2010 14:05 2026. 745 CAPITAL CARE PAGE 11

PRINTED; Q8122/2010 FORM APPROVED

STATEMENT OF DEFICIENCIES Art0 PLAN OF CORRECTION

(No pRovirowsupeuERicuA SIFJOTEICARON 1ST. • '

HP012.0674

(X23 RUMPLE A MALMO II. YONG

CONSTRUCTION OM DATE SURVEY CONFLETED

Ceill /2610 NAME OF mamma OR SUPPLER

CAPITAL CARE

STREET ADDRESS, CRY, STATE BP CODE UM HARTFCRO STEM SE INASHROTOLI, 00 20020

ZgOt

TAG

StIND/ARY STATEMENT OF DEFICIENCIES IEOICH DEFICIENCY 441ST 8 PflECEDEO BY FULL

RESINATCIRY OR LSC EINENTIEVNG !WOO: NATION

0 PREFIX

TAG

PROVIDEFFS PIAN OF CORRECTION MACK CORRECTIVE ACTION SNOW) BE

CROSS-REFERENCED TO THE APPROPRIATE OEFTOOICY)

Ott OmmEm GATE

1375

1 50CI

CODgned From page 7 for puCing out his G-Tube. 3_ 12/29/2009, Resident #4 sent to the ER for lethregy and dculty eabYlg. 4. 4/30/2010, Resident 06 wee taken to the ER for eaccassive omega.

Interview with the fealty • s Qualified Meritd Retardation Prates:signal (WARP) and the Reskbrdiai Coordinator (RC) on 6/112010, at apprOximately 6:30 p.m., confirmed the information was not on fits and that the ovonsight would be corrected immediately.

3523.1 RESIDENTS RIGHTS

Each GHMRP residence director she ensure that the rights of resklents ere obsessed and protected In accordance with D.C. Law 2-137, this chapter, and other applicable District and federal laws_

This Statute is not met as evldenced Or Based on observation. stzff intents". and record review revealed the group home for the mental,

retarded persons (GHMRP) trifled to enact and erdorce the necessary measures to ensure chard ' a rights as presented In the following cilations:

The findings Include:

Ttra fociEly Wed to ensure an effective invielnantetiOn of client' a rights to medical and rehablItathre care as presented In citations §3502.14, §3505.5, and §3519.6.

1376

1500

3523.1 See 3502.14, 3505.5, and 3519.6

Minot ireopOalon AesablatTcOon STATE FORZA C=2 osier t Ocontirtaead Ox=t a Of

4701_5 1. Staff # 5's criminal re-cord will be

expanded to include California where she lived within 7 years of employment.

2. Staffs #7, ti t4 and #15 will be expanded to include the District of Columbia where they lived within 7 years of employment-

Capital care will ensure that all individuals receive background checks nationwide to cover all staff in the future.

7/10110.

TTnE Ca) DATE

06/29/2010 14:05 2026, /45 PAGE 12 CAPITAL CARE

PRINTED: 081222010 FORDA APPROVED

Heig‘h FtwuWW1 STATECENT OP OEFXRENCRES APR) MAX OF CORRECTION

STREET somas, are. STATE, 2111 GEE

21320 HARTFORD MET. SE infAtenIGITC2f, DC 20020

GARY sTAIMENIT or DEFICIENCIES (EARL OEFICIERCY MIST BE PRECEDED BY RAIL Passx

REGULATORY OR LBO IDEPITTFyno wow:mum TAG

eul_TtpLE TION

A. BUED:NG

OM CATE SURVEY COMPLETED

0611 41201 0

NAME OF PROVIDER OR SUPPLIER

CAPITAL CARE

oci) pRovtuERIBUFFUERRliA EDEtrnFICATION WAINER

ifFO12-0974

(X4) i() PR EL

TAG

PRO•AGERS PLAil OF CORRECTION MACH LX:RRECTrYt AanoN SHOULD es

CR03E-REFERENCED TO 1HE APFROPIRME oencvalov)

R coo INITIAL CCILBAENTS

A re-Ecensure survey was conducted on 6/11/2010 A random sato* of MIER reekkeras war selected from a resident population of four males and two ferrades with varying cognitive and adapts/0 disabilities. The &dings of the survey were based on observations, staff intenteers, as wag as a review of the resident and administrobve records, including the unusual incident reports.

R 125 470t5 BACKGROUND CHECK REQUIREMENT R 125

The criminal background check she cbsclose the crininal history of the prospective amp:oyes or contract Olicer Tor the previous seVan (7) year*

juriscliceons rrIBIGI which the prospecdve I employee or contract worker has 'milked or

I resided within the seven (7) years prior to the Check.

This Mishit° is not mot sa evidenced by Based on record rev-ovs laid et ? bitervietv, the facility Wed to provide evidence that airsinal beekgroursd checks covered the Seven year Wort

I and residence history of each staff pilot to their start of ernptotirnent for four (4) out cf sbdeen (18) OW (Staffs 05, 07, 014 and 015]

The finding Includes

Record review and intonfrew gra %CARP ' s Residential Coordinator (RC) on 811112010 . approximately 5:25 o•m_, confrrnsci the folowing delictent preCtice&

1. Stag s records reflect they either fNed cr worked in the state of Catfornta wahin the seven

years odor to the screening, but the Orkfltrwei

background check only covered the state of Maryland.

!WM IWRcBco iiefrAtatchttion

LABORATORY DIRECTORS OR PROSKDER/SLIFfilLN RB4RESENTATNES SIGNATURE goonietadan shad 1 cr2

COMPLETE CATE

R 000

pug DATE SURVEY ComptzTED

Oa19112010

(X31 ODATIPLE CONsTRUCTION

A StAUXNO SAVING

06/29/2010 14: 05 2026, _ .745 CAPITAL CARE i

PAGE 13

PRINTED: Dein12010 FORM APPROVED

STATEMENT OF amblesPiss AND PUN OF CORRECTION

Health ReOsikan Athritrustrelion 00) pRovIDENSDPIILMINCUA

IDEMDFICATPON NUM%

HIFD1241174

MARIE OF PROVIDER OR SUPPLIER

CAPITAL CAM

PPM( TAG

R 125 Continued From page 1

SWEET ADDRESS. arc STATE. ZIP CODE

2820 HARTFORD srea, SE WASHINarCai DC WON

PROVIDERS plAN Of CORRECTION SCAM CORRECTIVE AcTion SHOULD SE

CROSSAEFSEXCED TO THE APPROPRIATE DEFICIENCY)

R 125

SUMMARY STATEMENT OF DEFICISSiCCES CEAl21 DEFICIENCY MUST PE PRECEDED SY FULL

Reoutmorn, DR Lac IDEPOTFYING iNFORMTIONI

;a paEfix

TAG

2. Stuffs 07, 014 and 015 ' s records retied they either Ned or worked in the District of Columbia wiltin the seven years prtor to the &weeding, but the criminal becknround chea only covered the state of 1.1elyiend•

•••••••■■••MNIII...••••• ■•■■••■■••■•......P...

Health Rept:tan ivinitribtnsiali STATE Foam

ceb CISJB11 r,tast 2 at 2

Dag covaotErr DATE