Facility Evaluation Report

On 01/28/2026 at 10AM, Licensing Program Analysts (LPAs) Renese Howell-Small and La Vette Farlow conducted an unannounced visit to the facility to deliver investigation findings for complaint control 56-AS-20231220154602. In addition, LPA issued citation for licensee violation of Title 22 Regulations.

Based upon Department Investigation of complaint control 56-AS-20231220154602, it was found that facility staff did not ensure that R1 was observed as needed. According to review of facility and other records and interviews with pertinent individuals, it was reported that R1 was seen awake around 10 pm on September 16, 2023. Facility staff admitted that per facility policy, residents are to be checked (for health and welfare) every 30 minutes. However, R1 was checked (via visual observation from the door) around 2:00 am. R1 was not checked again until around 5:00 am, when R1 was in bed, and observed to not be breathing. Emergency services were contacted. According to medical records reviewed, responding medical personnel reported signs of death including rigor mortis.

The following deficiency is issued per Title 22 Regulations. An exit interview was conducted where a copy of this report along with appeal rights were provided to Administrator, Vivian Francisco.