Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on deficiencies cited during complaint investigation #21-AS-20250602090022. During today's visit, Administrator provided information about facility policies and procedures implemented are been followed:

- §1569.269 (a)(6) - written plan ensuring that the facility is following up on resident's needs timely. During today's visit, LPA learned that facility staff that performs assessments are receiving additional training to learn how to perform accurate assessments of residents' care needs. Administrator agrees that care plans for all residents will be reviewed for accuracy.

- 87411(a) - Based on records review, the facility census revealed that there are five floors for assisted living residents where currently there are approximately 74 residents. The facility provided staff schedule for the month of June 2026 indicating that there are one med-technician (med-tech), two care staff for assisted living (AL) for morning and afternoon shifts; one care staff for AL and one shared med-technician who alternates between memory care and assisted living units at night. There are three care staff for memory care (MC) for morning and afternoon shift; one med-tech and two care staff (MC) for night shift coverage according to the amount of residents in care of 25 residents.

- 87625(b)(3) - staffing schedule for the month of June 2026 reflects current staffing got to assist residents with incontinent care needs timely. According to administrator, there are about 12 residents in AL needing assistance with incontinence care, behavioral concerns or two-people assistance, which staff are able to meet their care needs timely.

No deficiencies found during today's visit. Exit interview conducted with Administrator and copy of this report was given.