Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived to conduct an unannounced Case Management visit at the facility at 02:22 PM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan . The Administrator arrived to the facility at 02:28 PM. Entrance interview conducted and the reason for the visit was explained.

During an investigation into a complaint against the facility LPA interviewed the facility Administrator. The Administrator stated that upon admitting resident #1 (R1) to the facility they did not perform a pre-admission appraisal on the resident. LPA informed the Administrator of the importance of conducting pre-admission appraisals on residents. The Administrator expressed understanding and confirmed that they will conduct pre-admission appraisals on all future residents.

During the physical plant tour LPA observed the facility's front door to be equipped with an auditory alarm. LPA observed the alarm to be switched off. During an interview with staff #1 (S1) they revealed that on 03/01/2025 a resident eloped from the facility. S1 stated that they turned off the alarm in the morning and did not hear R1 leave the facility. LPA informed the Administrator of the importance of auditory alarms being functional and active. The Administrator expressed understanding and confirmed that auditory alarms would remain active.

The following deficiencies were cited (refer to LIC 809D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.