Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management – deficiencies visit at the facility. LPA arrived to the facility at 01:28 PM. LPA met with facility staff who contacted the facility Assistant Administrator, Tina Arutyunyan, via telephone call. The Assistant Administrator was unable to come to the facility during today's visit. Entrance interview was conducted and the reason for the visit was explained.

During a complaint investigation visit to the facility on 05/09/2025 LPA interviewed the facility Administrator, the assistant Administrator, and Staff #1 (S1) about an altercation that occurred between S1 and Resident #1 (R1) on 05/07/2025. During the interviews with the Administrator, the assistant Administrator, and S1 it was revealed that during the altercation S1 held the door to R1’s room closed and prevented R1 from leaving their room which resulted in R1 suffering a fall. LPA informed the the assistant Administrator, and S1 that personal rights of residents forbid staff from involuntarily secluding or locking residents in any room of the facility. LPA had a conversation with the goal of educating facility staff on the personal rights of residents and the appropriate responses to behavioral expressions of residents. The assistant Administrator, and S1 expressed understanding of the personal rights of residents and the appropriate responses to resident’s behavioral expressions.

The Assistant Administrator was unable to come to the facility during today's visit but has designated S1 to sign this report on their behalf. This report was read to the Assistant Administrator via telephone call. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.