Facility Evaluation Report

In conjunction with the complaint number 31-AS-20251028093801 , Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, it was confirmed that no physical file existed for Resident #1 (R1) at the facility. Interview with Staff #1 (S1) revealed that R1 was admitted to the facility on or around November 1, 2025, and remained for a few hours before being transferred to the hospital. Additionally, LPA observed that Room #3 was vacant. During the interview with S1, S1 indicated that Resident #2 (R2) is currently hospitalized. LPA conducted a record review and noted that no Special Incident Report (SIR) had been submitted to Community Care Licensing (CCL). Furthermore, it was discovered that the facility has not had a certified administrator since June 6, 2025. LPA also detected the smell of cigarette smoke during the physical plant tour. When asked, S1 denied smoking and stated that the odor was from a neighbor. Subsequently, a pack of cigarettes and a lighter were found in the kitchen. Moreover, LPA requested the LIC 500 – Personnel Report. S1 stated that only she and one other staff member live and work at the facility; therefore, no employee schedule is in place.

Exit interview was conducted, citations were issued, appeal rights were provided, and a copy of this report was signed and delivered.