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Allegation investigated: Staff are allegedly under the influence of, or possessing, alcohol while on duty inside the facility. Facility staff are allegedly hosting unauthorized social gatherings and events on-site, disrupting operations.

At 1:00pm, Licensing Program Analyst (LPA), Angela Panushkina conducted a subsequent visit to deliver final findings. LPA met with Sharon Nasio, staff, who granted access to the facility. LPA contacted the Administrator, Chinweike Okonkwo, and explained the reason for the visit. During the initial visit conducted on 07/01/26, LPA requested resident and staff roster. At 10:15pm, requested copies of pertinent information which include, but not limited to Staff 1(S1's) Personnel Records/Job Application, Education Verification, Facility House Rules, Employee Responsibility Policy, Staff Training, etc., relevant to the investigation. At approximately 10:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am - 11:30am, LPA conducted an interview with the Administrator, House Manager, one (1) staff and three (3) out of four (4) residents. During today’s visit, LPA requested resident and staff roster. Continue on LIC9099-C Unsubstantiated Allegation: Staff are allegedly under the influence of, or possessing, alcohol while on duty inside the facility. It was alleged that the live-in staff/House Manager is consuming alcohol on the facility premises. To investigate this allegation, LPA conducted an interview with the Administrator, two (2) staff members, and four (4) residents. LPA also conducted a physical inspection of the facility, including common areas, the kitchen, outside trash receptacles, and Staff 1’s (S1) room. The Administrator interviewed denied the allegation and stated that the facility has a strict policy prohibiting staff from consuming or possessing alcohol while on duty. The Administrator reported no knowledge of any staff violating this policy. Both staff members interviewed denied being under the influence of alcohol while working and denied possessing alcohol on facility grounds. Staff stated they are aware of the facility’s policy and adhere to it. Three (3) out of four (4) residents interviewed stated they have never witnessed staff working under the influence of alcohol and have not observed staff possessing or consuming alcohol while on duty. No residents reported concerns related to staff intoxication or alcohol use. Lastly, during the initial visit, LPA conducted a walkthrough of the facility: no alcohol bottles or containers were observed in the outside trash, no alcohol was found in the facility refrigerator, no alcohol was observed in S1’s/House Manager’s room or any staff areas and no signs of staff impairment or intoxication were observed during the visit. Based on interviews conducted, observations made, and lack of evidence to support the allegation, there is not enough information to prove that staff were under the influence of, or possessing, alcohol while on duty inside the facility. Therefore, this allegation is deemed Unsubstantiated, at this time. Allegation: Facility staff are allegedly hosting unauthorized social gatherings and events on-site, disrupting operations. It was alleged that the live-in staff/House Manager is throwing parties at the facility. The Administrator interviewed denied the allegation and stated that staff are not permitted to host personal gatherings or events on facility property. The Administrator reported no knowledge of any staff violating this policy. Both staff members interviewed denied hosting any unauthorized social gatherings or events on-site. Staff stated they are aware of facility rules and confirmed that no such activities have taken place during their shifts. Residents interviewed reported they have never witnessed S1 or any staff hosting unauthorized social gatherings or events at the facility. Continue on LIC9099-C Residents stated that staff conduct themselves professionally and facility operations have not been disrupted by any staff-related activities. Lastly, during the visit, LPA conducted a walkthrough of the facility, including common areas, outdoor spaces, and staff-accessible areas. No signs of gatherings, party supplies, decorations, or event-related materials were observed. No unusual noise, activity, or groups of visitors were present. Facility operations appeared normal and consistent with regulatory expectations. Therefore, based on interviews conducted, observations made, and the absence of evidence supporting the allegation, this allegation is deemed Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 31-AS-20260623161006

Type of visit: Required - 1 Year

At 11:00am, Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced annual inspection at the facility mentioned above. LPA met with the House Manager, Akampa Rachel. The Administrator arrived shortly after and the LPA explained the reason for the visit. At approximately 11:10am, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet (#10), medications observed to be locked in the kitchen cabinet (#7) and chemicals and cleaning solutions were locked under the kitchen sink and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. There is a fully charged fire extinguisher in the kitchen. LPA observed four (4) bedrooms are designated for residents’ use. All bedrooms have sufficient lighting, properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Bedroom #1 is designated for live-in staff. There are two full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 111.3°F. LPA observed appropriate grab bar and non-skid mat. All trash cans in bathrooms had fitted lids to protect them from cross contamination. The facility maintains a comfortable temperature at 71°F. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. Continue on LIC809-C At 12:00pm, smoke and carbon monoxide detectors were tested and observed to be operable. At 12:10pm, LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The outdoor area was free of visible immediate hazards. LPA discussed the importance of maintaining care and supervision to meet the needs of residents. Between 12:30pm to 1:30pm, LPA reviewed records of four (4) residents and two (2) staff. Residents and staff records appeared to be complete and updated. LPA observed Administrator certificated renewed on 01/25/2025 with an expiration date of 01/24/2027. LPA collected Certificate of Liability Insurance and LIC500. No citations were issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Required - 1 Year

At 12:20pm Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Rachel Akapma, who granted access to the facility. At approximately, 12:25pm physical tour was conducted with the staff and LPA observed the following: Kitchen: At approximately, 12:27pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. There is a fire extinguisher was last serviced on 05/07/2024. Medications: At approximately, 12:30pm LPA observed medications are centrally stored and locked in the cabinet, by the kitchen area and inaccessible to residents in care. Bedrooms: There are five (5) bedrooms, four (4) of which are designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility also has a live-in staff. Auditory alarms were tested and observed to be operational. Bathrooms: At 12:55pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 118.5°F. LPA observed appropriate grab bar and had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Continue on LIC809-C Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:40pm they were tested and observed to be operational. Outside areas: At approximately, 1:10am LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. Between 1:30pm to 2:30pm, LPA reviewed records of four (4) residents and two (2) staff. Resident and staff records appeared to be complete and updated. Administrative: Annual fee is current. All required signs are posted. LPA collected LIC500. Administrator will email Certificate of Liability Insurance and Administrator Certificate. No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.the state’s words, verbatim · CDSS document, Feb 18, 2025

Allegation investigated: Staff member is financially abusing resident in care.

At 09:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Staff #1 (S1) who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit. During course of the investigation, interviews and record review were made. At 09:40am, LPA requested client and staff roster. At 09:55am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Client/Resident Personal Property and Valuables, and the Record of Client's Sefeguarded Cash Resources relevant to the investigation. At approximately 10:00am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:10am – 1:00pm, LPA interviewed C1's family member, a Social Worker from the Department of Health Services (DHS), the Administrator, two (2) staff, and four (4) clients. Continue on LIC9099-C Unsubstantiated Allegation: Staff member is financially abusing resident in care. It was alleged that Staff #1 (S1) borrowed money from Client #1 (C1) amounting to approximately $700.00. To investigate this allegation, LPA conducted an interview with the Administrator and S1 and both denied the above allegation. LPA was informed that clients can access their funds by making a request. After the request, the funds get disbursed in the form of cash and a P&I log is being signed by the client upon receipt. A copy of P&I log records was also provided to LPA. Moreover, LPA was informed that C1 is able to manage his/her own cash resources and leave the facility unassisted. Administrator and S1 stated that C1 doesn't tell anyone where the money are spent and the staff will not question by respecting C1's Personal Rights. LPA conducted interviews with four (4) clients and all clients confirmed that they receive their P&I funds upon request and expressed no concerns regarding this allegation. Clients also informed LPA that no staff ever asked to borrow money nor they witnessed others giving/landing money to the staff. Lastly, LPA conducted an interview with C1's family member who denied the above allegation and also expressed no concerns. Based on today’s interview, record review and the information gathered, this allegation is deemed Unsubstantiated at this time. No deficiency cited Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 31-AS-20241021091302

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 10:11 am Chinweike Okonkwo who is the administrator met with LPA, explained the reason for the visit. At 9:36 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date of 2/7/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents. Facility has two (2) hospice waiver. Facility has no issue with fire clearance. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen. Bedrooms: There were five (5) bedrooms in the facility. Bedroom #1 is for staff used. Bedroom #2 is for private resident used. Bedroom #3 , Bedroom #4 and bedroom #5 are shared bedroom for residents, but bedroom #4 is empty right now and bedroom #5 has only one occupant. All of the bedrooms are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C Bathrooms: There are two (2) bathroom in the facility, but only one (1) bathroom is designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 116.2 degrees Fahrenheit for bathroom #1 located in the hallway across bedroom #3. Bathroom #2 is inside staff bedroom for private used. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. There is no garage in the facility, only car ports. Fire place is closed and non-operational. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the kitchen area. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the common area by the entrance of the facility. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisals 1 out of 4 is incomplete. Also, 1 out of 4 physician report is not filed. Liability insurance copy was handed to LPA. Planned activities are offered. Under Title 22, Division 6, Chapter 8, the following citations were issued and recorded on LIC809-D. No other health and safety hazard is noted. Exit interview was conducted; appeal rights were discussed and copy of report was issued.the state’s words, verbatim · CDSS document, Feb 7, 2024