Facility Evaluation Report

On this day, April 1, 2026, at 10:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection to follow-up on the complaint investigation (Complaint # 15-AS-20260226143854) LPA conducted on March 3, 2026 to ensure the health and safety of residents. LPA met with Associate Executive Director (AED) Tracy Gibson and informed the reason for visit.

LPA toured the Memory Care Unit with AED. LPA randomly selected 7 residents' rooms. The rooms were observed not locked except for 1 due to resident was out of the facility. Some of the residents were inside their rooms. LPA also observed 6 residents in the dining/activity area doing activities. LPA obtained copy of resident roster.

No deficiency observed during today's visit.

Exit interview conducted and copy of this report provided.