Facility Evaluation Report

On Tuesday June 30, 2026 Licensing Program Analyst (LPA) Nancy Guillen conducted an unannounced Case Management- Deficiencies visit. The visit is being conducted in conjunction with complaint control number 22-AS-20260627090909. Administrator(AD) Regat Kebede was notified via telephone and later arrived to assist with the inspection.

During the investigation into the complaint, LPA toured the facility, requested documentation and did a health and safety check on the residents in care.

At approximately 8:30am, LPA observed the medication cabinet to be unlocked and accessible to residents in care. LPA asked Administrator to lock the cabinet. AD called Staff 1(S1) to lock the medication cabinet. S1 proceeded to look for keys. While S1 looked for the keys LPA asked S1 how long the cabinet had been unlocked for. S1 stated it was unlocked for "about 20 minutes." The key was found and the medication closet was locked with LPA present.

At approximately 8:40 am, LPA asked to see the staff room. LPA observed an individual (ID) siting in the room with the lights off. LPA asked the individual for their name and AD responded stating this individual was only there for an interview. LPA asked to speak to the individual privately. During the interview the individual stated, they had been at the facility since 6:30 am and are scheduled to leave at 6pm. They also stated the visit for today was to "do the job and they see how I do." LPA verified on Guardian that the application is currently pending. The individual was asked by the AD to leave the facility and ID left immediately after.