Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 01:15 PM. The purpose of this visit is to conduct an investigation regarding self-reported incidents that occurred on 07/24/2026 and 07/25/2026. LPA met with Executive Director (ED) Stephanie Funderburg and explained the reason for the visit.

During today’s visit, LPA conducted a physical plant tour to ensure there are no immediate health and safety hazards, interviewed three (3) staff members, and reviewed and obtained copies of pertinent documents.

On 07/31/2026, the Department received an incident report stating that on 07/24/2026, Staff #1 (S1) observed smoke emitting from unit #102’s bathroom exhaust fan. The resident was not in their room at the time of the incident. S1 followed fire safety protocols by notifying the Memory Care Director, while Staff #2 (S2) retrieved a fire extinguisher and extinguished the fire. The ED was contacted immediately for assistance. Prior to the to the arrival of the fire department, staff entered the unit to confirm that the fire had been fully extinguished. Circuit breakers were turned off, and the sliding door and windows were opened to ventilate smoke and extinguisher residue from the room. The fire department arrived shortly after and confirmed that power to the unit had already been shut off, noting that the breaker had tripped automatically during the incident. Fire personnel inspected the wiring connected to the bathroom exhaust fan and confirmed there was no damage to the ceiling or electrical wiring. A precautionary walk-through of the property was also completed before departure. Following the incident the facility contacted Cintas, a fire protection service provider, to investigate why the fire alarm system did not activate.