Facility Evaluation Report

Announced office visit was conducted, via Microsoft Teams, on 2/3/2026 by the following participants: Stephen Richardson, Licensing Program Manager (LPM); Arvin Villanueva, Licensing Program Analyst (LPA); Chukwudi “Patrick” Ikiseh, Facility Co-Licensee.

Note that Co-Licensee, Sylvester Okoro, was invited to this meeting but did not attend.

The purpose of this office meeting was to discuss the complaint investigation regarding Complaint #27-AS-20250430095638 . The following information was obtained:

Facility Oversight: Patrick stated he is overseeing the operations of the facility. Patrick confirmed that Co-Licensee Sylvester Okoro is not physically involved in the facility’s operations.

Staff Roles: Patrick confirmed that Staff #1 (S1) serves as the supervisor and communicates facility needs and updates to Patrick.

Staff Performance: Patrick stated that Staff #2 (S2) was considered a good caregiver but noted concerns regarding S2’s alertness and follow-through. Patrick reported there were no documented complaints about S2 prior to R1’s incident.

Alarm Procedures: Patrick stated that door alarms are required to remain on throughout the day and staff are not permitted to turn them off. Patrick indicated this expectation was verbally communicated to staff. Prior to R1’s incident, Patrick reported no information suggesting alarms were turned off while staff were on duty.

Incident Details: Patrick stated that although S2 reported the alarm was on and did not hear it, Patrick expressed doubt that the alarm was active during R1’s incident.

Corrective Actions: Following the incident, Patrick installed a louder door alarm and cameras to monitor overnight activity.

Documentation: Patrick stated he will provide requested documents by Friday, 02/06/2026 , and will submit a new administrator appointment letter for the facility.

No deficiencies were cited during this visit. An exit interview was held with all parties.

A copy of this report was emailed to Patrick to be signed and returned a signed copy to the Department.