Facility Evaluation Report

On 06/11/2025, Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM) Troy Agard returned to issue additional citations for deficiencies observed during a previous Case Management visit.

On 06/06/2025, LPA Melissa Spaeth and LPM Troy Agard conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #31-AS-20250605130645). Due to time constraints, the licensee was informed that additional deficiencies would be cited at a later date.

During the LPA/LPM physical plant tour and record review, the following deficiencies were observed:

· 80065 Personnel Requirements: No criminally clear staff present at the time of the visit, initially.

· 80075 Health Related Services: Client was observed using oxygen with no professionally trained staff present.

· 80087 Buildings and Grounds: Facility was observed unkempt, including milky white still water in the water fountain; presence of pests (roaches and flies); dog feces; dirty dishes; dirty tub, toilet, and sink; broken wall in bathroom; broken fire detectors in