Facility Evaluation Report

On 07/23/2025 Licensing Program Analysts (LPAs) Deniz and Felias conducted an unannounced case management Legal/ Non-compliance inspection to this facility and was greeted by Executive Director Camille Brown. LPAs are following up on items identified during a non-compliance conference dated 04/23/2025:

· Staff not adequately supervising residents in care

· Lack of supervision resulting in resident injuries

· Changes to LLC/Management Company without notifying the Department

LPAs requested and reviewed documents for all employees hired from May 2025 to July 2025. Review of facility records indicated that 16 individuals have been hired. LPAs reviewed a sample size of 8 staff records. Record Review indicated that training has been conducted or has been scheduled for the following areas: Observation of a resident, Pressure Injuries, Incontinence Care, and Personal Rights.