Facility Evaluation Report

On 04/17/2026 at 1:00PM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the facility in order to conduct a Case Management - Plan of Corrections visit. LPA was greeted and granted entrance by staff. LPA introduced self, stated the purpose of the visit and met with staff, Jay Ruba.

LPA requested to see the following: Infection Control Plan, staff files, staff training logs and the emergency and disaster drill. LPA observed that the closet where files are kept to be locked and staff did not have a key or access to the files. LPA informed the Administrator, Sachin Mathur that the staff and resident files should be available for Community Care Licensing Division (CCLD) during the annual inspection completed on 04/07/2026. The Infection Control Plan was not available for review and the staff could not provide documentation for staff training(s). LPA was unable to review staff files. Deficiencies will be cited.

Three (3) deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and copies were provided to staff, Jay Ruba.