Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding a deficiency LPA observe. LPA met with staff and explained the purpose of the visit. Additionally, LPA spoke with Administrator via telephone to discuss the concerns observed.

Upon arrival, LPA observed the front gate to be in disrepair. LPA contacted facility telephone and spoke with staff. Staff then met LPA at the gate. LPA and staff attempted to realign the gate for LPA to enter the facility; however, LPA then observed residents in care needing assistance with redirecting. LPA was informed there is only one caregiver working at the moment.

LPA contacted Licensee who informed LPA front gate has been in disrepair since last week but mechanic was unavailable to come to the facility to fix it. When asked, Licensee stated staff informed Licensee of the gate on Wednesday September 10, 2025. LPA informed Licensee the following deficiency is a fire safety concern as facility is not appropriate for locked perimeters, and there is no way for residents to exit and/or reenter. LPA observed the gate to extend to approximately 8 to 10 inches only.

As a result of today's visit, deficiencies cited. Please see LIC 809-D. Additionally, immediate civil penalty of $1000 was accessed today as fire safety violation is a repeated violation. Plan of correction due today. Failure to correct may result to additional $100 per day until plan of correction is received.

Exit interview and a copy of report and appeal rights provided.