Non-compliance follow-up·July 3, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Meghian Geul. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA toured the memory care unit and tested the delayed egress doors in the memory care unit with ADM. The delayed egress doors made an auditory sound when pressed and needs to press the correct code to open. LPA toured the exit door of the garage and the main entrance with ADM. LPA reviewed the resident check-out and check-in log for June and July 2025. LPA reviewed the memory care unit exit door checking log for April, May, June, and July 2025. LPA reviewed staff elopement training log for April, May, and June 2025. LPA reviewed staff in-service training log in April 2025 - June 2025 including but not limited to on topics : Medication error prevention, Resident right to privacy, reporting change in condition, reporting requirement. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.