Facility Evaluation Report

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Case Management visit to the facility. LPA met with Administrator Denise Sutton and discussed the purpose of the visit which is to reissue a citation from a 03/09/26 Case Management visit to the facility. The reason the citation is being reissued is to clarify language on the Licensing Report and on the LIC 809-D.

On today’s visit LPA requested and obtained and staff and resident roster and a copy of S1’s government ID. LPA toured the physical plant and did not observe any immediate health and safety concerns.

On 03/09/26 LPA reviewed the LIC 500 Personnel Report and found that Staff 1 (S1) had been working as an Administrative Assistant at the facility since 06/17/2025. S1 was cleared, however, S1 was not associated to the facility at the time of the 03/09/26 visit. The facility did not transfer S1's Criminal Record Clearance to the facility.

A Type A deficiency was cited on 03/09/26 along with immediate Civil Penalties, which have been dismissed by the department. The Type A deficiency along with Immediate Civil Penalties are being reissued on today’s visit in the amount of $500. Refer to LIC 809-D.

An exit interview was conducted with Administrator Denise Sutton and copy of this Licensing Report was provided along with Appeal Rights.