Facility Evaluation Report

On 10/20/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Plan of Correction (POC) visit.. LPA was greeted by Staff Member (SM), Carlette Sharpe and explained the purpose of the visit. SM Sharpe notified the Facility Designated Representative (FDR), Nicolette Taylor that CCL was present. SM Sharpe notified LPA Pascua that FDR Taylor would be arriving shortly. LPA Pascua asked SM Taylor to contact the Facility Designated Administrator (FDA), Iboni James to inform them that CCL was present. It was learned that FDA James was unable to be reached during the time of this visit. There was one other staff member present, Carlette Sharpe.

Current census was 3. A brief interview with SM Taylor was conducted.

The purpose of this case management visit was in response to additional information learned during a complaint investigation delivered on 10/20/2025. Based on the investigation the following violations were learned: Personal rights, Personnel Requirements, False Statements, and Administrator Qualifications.

Based on interviews and a review of facility records, it was determined that on October 8, 2025, at approximately 5:00 AM, Resident 1 (R1) was found asleep in the facility’s backyard with a guest. Staff 2 (S2) discovered R1 and woke them by shining a phone light in their face. R1 responded by stating they did not want to get in trouble and would leave if necessary. S2 assured R1 they were not in trouble and allowed them to continue resting.