Facility Evaluation Report

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan due to increased complaint volume, prior issues observed to include but not limited to insufficient staffing .

Upon arrival, licensing representatives observed the following:

· The facility did not have sufficient support staff.

· LPA Smith and LPM Margaryan observed no front desk staff present. They remained at the front desk for approximately 20–30 minutes before a maintenance worker arrived to assist.

· On 04/06/2026, LPM Margaryan conducted a follow-up call with the Executive Director (ED), who confirmed that the facility does not currently have an employee assigned to the front desk.

· The facility continued to lack adequate staffing to meet residents’ needs. During the licensing visit on 02/27/2026, LPA Smith and LPM Margaryan detected a strong urine odor in the elevator, third-floor hallways, and common areas. They observed a resident in a wheelchair who was wet and emitting an odor of urine, and/or feces. On the third floor and throughout the facility, only one caregiver was on duty to provide care and supervision for all residents.