Facility Evaluation Report

On October 30, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding an incident that occurred on October 9, 2025. LPA met with staff and explained the purpose of the visit. Today's visit, LPA was informed Administrator is unavailable due to an emergency.

Today's visit, LPA obtained resident 's (R1) whole file. In accordance to:

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

(3) Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed.

LPA may return R1's file within three business days by Tuesday November 4, 2025.

This matter is still under review by the Department.