Facility Evaluation Report

Unannounced case management visit made out to this facility on 10/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Avinesh Ram, at this time. A brief interview was conducted with the facility designated Administrator at this time.

The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 02/27/2025 and the requirement to have increased monitoring at that time.

The focus of this quarterly visit was to review the following items that were initially brought forth on 02/27/2025:

Complete and submit the LIC 500 for the most current staff, shifts, and coverage for designated shift leads.

Complete and submit proof of most recent training in the areas of Resident Personal Rights, Resident Care and Resident Supervision and Reporting Requirements. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees.

It was learned that this facility has failed to engage with TSP for services and resources since the Non Compliance Conference at this time. A brief discussion was held with the facility designated Administrator in regards to this matter and the need for this facility to respond to all communications with TSP.