Facility Evaluation Report

While at the facility conducting inspection with Thinn Aye, administrator (ADM), for investigation of a complaint (Control # 15-AS-20250825103605), Licensing Program Analyst (LPA) Delmundo observed dividing walls and 2 beds in the garage.

After granting of fire clearance by fire department on 1/22/25, and before granting of license, pre-licensing inspection was conducted by LPA on 3/13/25. LPA observed rooms with permanent walls installed in the garage. LPA reached out to fire marshal, and ADM had the rooms demolished. LPA reached out to fire marshal again regarding the dividing walls installed in the garage. Per fire marshal, the dividing walls are not allowed and that the demolition of the walls on the garage and the explanation of not using it as habitable space was conveyed prior.The garage can only be used if permitted and constructed per code, otherwise, it should remain a garage.

On this day, 10/01/25, LPA learned and observed resident (R1) has 5 and 1 scratches/wounds on the lower right arm and left arm respectively caused by the dog in the facility. ADM stated the incident happened 2 days ago. On this same day, 10/01/25, the same dog came inside the facility and kept jumping on LPA.

LPA also observed resident (R2) with two half bed rails on one side of the R2's bed, and R2 is not on hospice.