facility_name: Timbert Haven

raw_content:
PRINTED: 03/31/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-250 B. WING 03/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

921 ANCHOR WAY NE

TIMBERT HAVEN KANNAPOLIS, NC 28083

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on March 26,
2025. The complaints were unsubstantiated
(intake #NC00227962, #NC00228114,
#NC00228256, #NC00228298, and
#NC00228292. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.

This facility is licensed for 4 and has a current
census of 4. The survey sample consisted of
audits of 2 current clients.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 HBSR11 If continuation sheet 1 of 1


state: NC

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 02/28/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-250 B. WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

921 ANCHOR WAY NE
KANNAPOLIS, NC 28083

TIMBERT HAVEN

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on February
26, 2025. The complaint was unsubstantiated
(intake #NC00227468). No deficiencies were
cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.

This facility is licensed for 4 and has a current
census of 4. The survey sample consisted of
audits of 1 current clients.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 JDRD11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


facility_name: Peaceful Ways

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL013-251

518 EAST C STREET

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
09/29/2025

A limited follow up survey for the Type A1 was
completed on 9/29/25. This was a limited follow
up survey, only 10A NCAC 27D .0304 Protection
from Harm, Abuse, Neglect or Exploitation (V512)
was reviewed for compliance. The following was
brought back into compliance: 10A NCAC 27D
.0304 Protection from Harm, Abuse, Neglect or
Exploitation (V512). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

6899

ZINS11

PEACEFUL WAYS
KANNAPOLIS, NC 28083
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up