Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Meghian Geul.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024.

LPA toured the memory care unit and tested the exit doors in the memory care unit with ADM. The exit doors made auditory sound when pressed and needs to enter the correct code to open. LPA tested the gate of the courtyard of memory care unit. The gate needs to enter correct code to open.

LPA toured Med room of memory care unit. The Med room was observed locked and two Med Carts were observed in the Med Room.

LPA reviewed staff in-service training log in December 2025 - February 2026 including but not limited to on topics : Medication error prevention, Resident right to privacy, reporting change in condition, reporting requirement and Elopement drill training.

The case management of inspections will be conducted every 3 months for 2 years.

No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.