Facility Evaluation Report

At approximately 10:20 a.m. on 03/04/25 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit.

Today's case management visit was conducted in conjunction with complaint investigation #31-AS-20250303144817 to issue previously identified deficiencies in the facility from a case management visit on 02/28/2025. LPA and LPM were unable to gain entry to the facility after several attempts. LPA called the administrator at 10:48 a.m. and disclosed the reason for the visit. The administrator stated their were no staff or clients at the facility today. The administrator’s representative joined the call and spoke for the administrator. The administrator’s representative stated they were unable to attend this visit at the current time and asked to reschedule the visit.

During Licensing visit conducted on 02/28/2025 the following deficiencies were observed by the LPAs Huma Rahimi and Nicholas Reed.

Fire Safety. Blocked and locked emergency exit. (Bedroom #2) The emergency exit was blocked with boxes and the doorknob was missing. The door was locked.

Fire clearance. Facility retained non-ambulatory resident R6. Fire clearance is approved to retain ambulatory residents only.

Criminal record clearance and association

Staff present in the facility without criminal record clearance or association to the facility.