Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection of this licensed senior care facility and met with Patricia Gustin, Administrator. The purpose of this case management inspection is to follow up on uncleared deficiencies cited during complaint investigation #21-AS-20250602090022 on 7/17/2025. As of today's inspection citations §1569.269 (a)(6) with POC date 7/18/2025, 87411(a) with POC date 7/18/2025 and 87625(b)(3) with POC 7/18/2025 are outstanding. LPA contacted Administrator on two occasions to follow up on POC's.

During today's visit, Administrator provided proof of correction for citations:

- §1569.269 (a)(6) - written plan ensuring that the facility is following up on resident's needs timely.

- 87411(a) - staffing schedule for the months of July and August 2025 as follow: one med-technician, two care staff for assisted living (AL) and three care staff for memory care (MC) for morning and afternoon shift; one med-technician, one care staff (AL) and two care staff (MC) for night shift coverage according to the amount of residents in care of 19-20 residents in MC and AL mainly resident's care needs are based on medication management. Written plan obtained ensures staffing is adequate to meet residents needs timely.

- 87625(b)(3) - staffing schedule for the months of July and August 2025 reflects additional hired staffing to assist residents with incontinent care needs timely.

Deficiencies cleared from 7/17/2025. Copies of documents obtained. Exit interview conducted with Administrator and copy of this report was given.