Facility Evaluation Report

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701 and while reviewing the facility’s insurance policy. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.

During today’s inspection, LPA inspected the facility and observed the following: while the facility was licensed with a single memory care on the first floor, LPA observed that an additional memory care has been set up on the third floor with functional delayed egress doors. Per interviews with AD and Licensee (LE) Erik Doan, the facility began keeping residents with memory issues in this third floor memory care early in 2025 in order to provide closer supervision and to separate them from the ambulatory memory care residents in the first floor memory care. AD and LE provided conflicting information regarding whether these residents needed to be in a memory care. However, the facility did not notify LPA of this new memory care with delayed egress, request an update to its plan of operation, or receive approval for this change and LPA first learned of this new memory care after observing it months after it was created. During the inspection, the maintenance manager attempted the deactivate the delayed egress doors but was unsuccessful. LE stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care. LPA advised LE on the process for properly requesting a new memory care for approval if LE is interested in adding a third floor memory care.