Facility Evaluation Report

On 05/29/2026, Licensing Program Analyst (LPA) Deniz conducted an unannounced case management Legal/Non-Compliance inspection at the facility and was greeted by Executive Director, Camille Brown. LPA conducted the visit as a follow-up to the previous Non-Compliance Conference inspection conducted on 04/23/2025 to assess whether there are any ongoing concerns related to previously identified deficiencies.

During today’s inspection, LPA conducted a walkthrough of the facility, reviewed facility operations, and discussed current practices with facility staff and the Administrator. The following areas were reviewed:

LPA observed residents to appear appropriately supervised at the time of the visit. Facility staff were observed providing care and assistance to residents. LPA reviewed staffing schedules and discussed staffing coverage with the Administrator. The Administrator stated that staffing levels remain adequate to meet resident needs. LPA obtained staffing training records in resident rights and incontinence care. The facility has a new complaint allegation that has been still investigated about “Lack of staff supervision” (Complaint number is 21-AS-20260406103215)

LPA conducted a walkthrough of the facility and observed that emergency exits were unobstructed at the time of the inspection. Infection control supplies were observed available throughout the facility.