Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to inspect the facility for an increase in bedridden capacity from zero (0) to twelve (12). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Marivel Johnson.

On September 12th, 2025, the licensee submitted an application (LIC 200) and Facility Sketch (LIC 999) to request an increase of their bedridden capacity from zero (0) to twelve (12) residents. Fire Safety Inspection Request was approved by the local Fire Marshal on January 15th, 2026, which granted the bedridden capacity to increase from zero (0) to twelve (12). Per the inspector, bedridden may reside throughout the facility property with special staffing and emergency operational considerations required per proposed resident unit.

LPA, along with Executive Director Johnson, conducted a walk-through of the Casa Loma building, where one (1) bedridden resident currently resides. Facility sketch provided by the Fire Marshal was consistent with the current layout of the facility, and no issues were noted by LPA.

This portion of the application process is complete and will be forwarded to management for final review and approval. The Licensee will then be notified of managerial approval by phone and the new license will be mailed to the Licensee.

No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.