Facility Evaluation Report

Licensing Program Analyst (LPA), Tiffany Holmes, conducted an unannounced Case Management visit to issue civil penalties based on complaint report issued on February 12, 2026. LPA met with Arlene Doulopoulos Administrator and was allowed entry into the facility after identifying herself and stating the purpose of the visit.

During the visit, civil penalties assessment was discussed with the Arlene Doulopoulos Administrator. Based on the substantiated findings from the complaint report issued on February 12th, 2026, the Department determined that the violation of same deficiency cited in the same year required an immediate civil penalty and it is being assessed in the amount of $1000. Civil Penalty listed on the LIC421IM.

During another visit on 02/13/2026 another civil penalty is being assessed in the amount of $2000 for 4 staff not being associated to the facility. LPA is citing for non fingerprinted staff on this case management.

Civil Penalty listed on the LIC421BG- CPA for $500 for 5 days for 4 staff. S1, S2, S3 & S4 ** Please see attached LIC 811 confidential names list**

The department also received an incident report on 02/28/2026 regarding an overdose at the facility for the same client that overdosed last week. The client was using drugs and interviews revealed emergency services (911) were called and arrived on the scene shortly after and administered Narcan to C1. The client went to the hospital on 02/12/2026. Interviews revealed the staff do rounds to check on the clients activity and safety. Interviews revealed that they plan to increase staff monitoring of the rooms, provide more staff training on signs of drug usage and reinforce the house rules that possession of illicit drugs is prohibited.

An exit interview was conducted and a copy of this report, LIC421IM, and LIC421BG CPA Licensee/Appeals Rights (9058 03/22) were provided to the Administrator, whose signature on this form confirms receipt of these documents.