Facility Evaluation Report

Licensing Program Analyst (LPAs), Ramin Hashemi and Amy Rodgers conducted an unannounced case management visit. LPA was greeted by, identified themselves to, and explained the purpose of the visit with Executive Director Cathy Allen.

The facility self-reported an incident that occurred on September 26, 2025, involving two involving Resident #1 (R1) and Resident #2 (R2). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].. Additionally, The facility self-reported another incident that occurred on September 29, 2025, involving Staff #1 (S1) inappropriately confining Resident #3 to wheelchair. The facility discontinued S1's involvement in resident care.

During today’s visit, LPAs briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents.

There were no deficiencies cited during today's visit. However, these incidents may require further follow-up visits.

An exit interview was conducted with Executive Director Cathy Allen, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.