Facility Evaluation Report

On 6/17/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director .

While conducting a complaint investigation for complaint number 59-AS-20260224132358, LPA Mknelly noted the following additional violation.

Facility staff failed to report the following as required: R1’s fall/ injury on 1/8/26 and hospital death on 1/15/26 were not reported until requested on 4/20/26; R8 had a fall with rib fractures on 12/25/25 that was not reported; On 4/2/26 a resident made an allegation of staff sexual misconduct, yet the department learned about the allegation on 5/19/26. This final incident posed an immediate risk to the resident as it is a mandated reporter violation.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided