Compassionate Care for Seniors 1

Allegation investigated: Licensee did not timely arrange medical care for resident. Licensee did not give resident medication as prescribed.

Licensing Program Analyst (LPA) conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Administrator Laith Sarsam. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, outside sources, and records review. On April 29, 2026, Community Care Licensing Division (CCLD) received a complaint alleging that the licensee did not timely arrange medical care for the resident and did not give the resident medication as prescribed, more specifically Resident #1 (R1) reported requesting medical attention for an extended period without receiving assistance and further reported experiencing long waits for pain medication at night. (Continued on LIc9099C) Unsubstantiated Department interviews with staff and residents report responding to resident needs throughout the day and night, stated they were unaware of delays in care, and confirmed medication was administered as prescribed. Department interviews with R1 revealed staff respond but not as quickly as desired. Department interviews with outside sources reveal R1 has made similar complaints at previous facilities and confirmed this has been a pattern at multiple prior placement's due to R1's inability to be satisfied. Department records review reveals the Medication Administration Record (MAR) and interviews with staff confirm all medications are being administered per physician prescription. LPA observations reveal staff were present and responding to residents and medication systems and storage appeared to be in compliance. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Laith Sarsam, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 7, 2026 · control 08-AS-20260429150146

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Rodgers was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee/Administrator Maja Bacinski . According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom can non- ambulatory of which 4 may be bedridden. This facility does not feature a secured perimeter or delayed egress doors. LPA accompanied by Licensee/Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Maja Bacinski, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Maja Bacinski . According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom must be ambulatory. During today’s inspection, there were a total of four (4) clients in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 110 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 111 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 110 F. Refrigerator temperature was 35 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Maja Bacinski, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 18, 2024