Facility Evaluation Report

On 02/11/2026 at 3:00 pm, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Licensee/Administrator, Thinn Aye, and explained the purpose of the visit.

While conducting complaint investigation 15-AS-20260204142916 on 02/11/2026, LPA conducted a record review and facility observations. During the visit, LPA observed that Resident 1 (R1) was residing in a room that does not have fire clearance for a bedridden resident. LPA also observed that the bedroom of Residents 2 (R2) and 3 (R3) was being used as a passageway to access the room where R1 is currently located.

Additionally, LPA observed the following:

Residents 1 through 6 (R1–R6) did not have completed Appraisal Needs and Services documents on file.

Residents 4 (R4) and 6 (R6) did not have updated Admission Agreements on file.

One-half bed rails were in use for Residents 1 through 4 and Resident 6 (R1–R4, R6) without physician’s orders on file.

Home health care plans were missing for Residents 1 (R1) and 2 (R2).

Resident 6 (R6) eloped on 12/11/2025. LPA received a copy of the Unusual Incident Report that Licensee Thinn Aye stated was submitted to CCLD.