Facility Evaluation Report

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to perform a health and safety check. Upon arrival, the LPA met with Executive Director (ED) Heather Scott, informed her of the purpose of the visit, and was granted access to the facility.

Community Care Licensing (CCL) received an incident report on November 7, 2025, alleging that Staff 1 (S1) made a threat toward Resident 1 (R1).

As part of the case management process, the LPA conducted an interview with facility staff, obtained relevant documentation, and toured the facility to assess for any health and safety concerns. No immediate health or safety risks were observed during the visit.

According to the ED, S1 has been terminated due to the threatening behavior exhibited toward the resident.

The ED was informed that additional follow-up, including possible phone interviews and future visits, may be conducted prior to a final determination.

An exit interview was conducted, and a copy of this report was provided to Executive Director Heather Scott.