Facility Evaluation Report

01/06/2026 11:!0 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrative assistant Ashlyn Kelley. Executive Director (ED) Stacey Baxter was unavailable for the visit.

In December 2025 the Department received notification that the facility fire alarm system has been experiencing ongoing issues which has generated a significant number of false alarms. On 12/04/2025 LPA issued a citation which required the licensee to replace the fire alarm system.

During today’s tour of the facility LPA confirmed that the new fire alarm system is in place and operating.

No deficiencies were cited. LPA will clear the deficiency. An exit interview was conducted and a copy of the report was provided to ED Stacey Baxter.