Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit regarding an incident report that the Department received. LPA met with staff and explained the purpose of the visit, staff contacted Licensee who arrived to the facility shortly afterwards.

The incident report reveals that resident (R1) was sent to the hospital on January 15, 2026 for a follow up on their blood work. R1 is currently in the hospital for drainage removal, with the discontinuation order of insulin.

LPA and Staff discussed that R1's health conditions has changed due to lack of eating and health deterioration where hospice services may be beneficial. Licensee informed LPA this matter has not been brought to R1's primary care physician's attention has Licensee has been unavailable.

LPA and Licensee discussed the importance of notifying primary car physician and responsible party regarding change of condition.

Licensee will update LPA once R1 is discharged from the hospital. Copies of R1's observation notes were obtained.

As a result of today's inspection, deficiencies cited.

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