Facility Evaluation Report

At approximately 8:30 a.m. on 05/04/26 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager Naira Margaryan (LPM) conducted a subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit.

This case management visit was conducted in conjunction with complaint investigation # 31-AS-20251120091051 visit to address the issues unrelated to the complaint. During Licensing Visit, LPM Naira Margaryan and LPA Nicholas Reed spoke with ED and VP of Health and Wellness. The following issues and concerns were addressed:

1. LPM, LPA, ED and VP discussed duties, responsibilities of the staff that are responsible for residents’ assessment, reassessment and care coordination. (ED will review job scope for each member managing group of employees, and revise job duties as needed).

2. ED and VP agreed that responsible personnel must provide proper assessment for any issues reported by the caregivers. Physicians and other medical professionals must be involved to ensure proper incidental medical care for each resident.

3. A review of medical records including hospital discharge documents must be completed after each hospitalization of the residents to observe, assess and reassess the residents during admission and/or readmission.

4. The steps facility should take If hospital records identify diagnoses and health conditions previously not addressed.

5. The importance of staff observation, reassessment of the residents and discussion with the Physician and other medical professionals attending residents.

6. Accurate record keeping of internal documentation of the issues addressed by the management upon receiving reports by the caregivers.

7. Immediate reporting all issues and concerns including changes in residents overall physical, mental and psychological conditions to ED as soon as possible.