Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding multiple incident reports that was submitted to the Department earlier this month. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit.

On the incident report submitted on August 1, 2025, it revealed the incident regarding R1 being aggressive towards other residents in care occurred on July 19, 2025.

On the incident report submitted on August 1, 2025, it revealed the incident regarding R2 being transported for evaluation occurred on July 23, 2025.

On the incident report submitted on August 7, 2025, it revealed the incident regarding R3 trying to get in R4's bed occurred on June 26, 2025.

On the incident report submitted on August 10, 2025, it revealed the incident regarding R5 touching R6's food which R6 then hit R5 in the face, triggering R7 to push R6 down on the floor occurred on June 10, 2025.

On the incident report submitted on August 11, 2025, it revealed the incident regarding R8 becoming weak and unable to respond occurred on June 30, 2025.

LPA observed an additional 12 other reports submitted to the Department that was reported outside of reporting requirement. Deficiencies cited. Please see LIC 809-D.

Exit interview conducted. A copy of report and appeal rights provided.