Facility Evaluation Report

On 10/07/2025 at 10:30 AM , Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. Upon arrival, LPA met with Medication Technician, Daffodale Fernandez , and explained the purpose of the visit. Licensee/Administrator, Elizabeth Cortes , was not available at the time of the visit. Daffodale contacted Ms. Cortes via phone, informed her of LPA’s presence, and received authorization to sign the report on her behalf. Ms. Cortes arrived at approximately 10:16 AM.

On 08/20/2025 , LPA Alexander conducted a Case Management visit during which a deficiency was cited with a Plan of Correction (POC) due date of 09/03/2025 . LPA was unable to conduct a follow-up POC visit within the 10-day period. The Administrator was required, per the POC, to complete a course through a Community Care Licensing Division (CCLD)-approved vendor but reported being unable to locate a vendor that covered the required topic. As a result, the deficiency will be re-cited with a new due date.

Additionally, during the 08/20/2025 visit, a POC review was conducted for the previously cited deficiency under HSC §1569.625 – Staff Training. The deficiency was not cleared, and civil penalties were assessed. As of today’s visit, the deficiency is cleared.