Facility Evaluation Report

On 01/14/2026, Licensing Program Analysts (LPA) Deniz conducted an unannounced case management Legal/Non-Compliance inspection at the facility and were greeted by Executive Director Camille Brown. LPA conducted the visit to follow up on items identified during the Non-Compliance Conference dated 04/23/2025.

The following areas were reviewed during the inspection:

• Staff not adequately supervising residents in care

• Lack of supervision resulting in resident injuries

• Changes to LLC/Management Company without notifying the Department

LPA requested and reviewed documentation regarding staffing ratios. Review of facility records indicated the facility has adequate staffing. One (1) out of the five (5) houses on the facility was closed due to low census. Staff members provide coverage across the remaining houses as needed. The Administrator stated that staffing levels are currently adequate. Facility in-service trainings have been completed in the following areas: observation of residents, pressure injuries, incontinence care, and personal rights.

The following concerns—staff not adequately supervising residents in care, lack of supervision resulting in resident injuries, infection control protocols, and changes to LLC/Management Company without notifying the Department—are currently being addressed through Complaint Investigations 21-AS-20250501124124, 21-AS-20250516100242, 21-AS-20250520084631, 21-AS-20250701124101, and 21-AS-20250404122536. Citations were issued where applicable under the identified complaints. Plans of Correction have been completed.