Facility Evaluation Report

In conjunction to the complaint 31-AS-20260123163356 , Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management – Deficiencies visit. During the physical plant tour, the LPA observed the following:

Bedroom #1: A strong odor of urine was present. Dirty bed linens were observed, along with clothing on the floor.

Bedroom #2: A full trash bag was observed on the floor, and clothing was noted on the bed.

Bedroom #3: A basket containing a pile of laundry was observed, the bed was unmade, and clothing was on the floor.

Bedroom #4: No bed frame was present in the room. Client #4 was sleeping on a mattress placed directly on the floor. Clothing was observed on the floor, and three baskets containing unclean laundry were present. LPA was informed that on January 17, 2026, Client #4 experienced a behavioral episode during which the bed was broken. No replacement bed had been provided at the time of the visit. Interview with the Backup Administrator revealed that facility staff encourage clients to clean their rooms; however, it was stated that clients ultimately decide whether or not to do so. LPA discussed with the Backup Administrator that the facility is required to ensure that the physical plant is maintained in a clean, safe, and sanitary condition and in good repair at all times to protect the health and safety of clients, staff, and visitors. The conditions observed during the visit did not meet this requirement.

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