Facility Evaluation Report

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Roxana Aguirre. LPA explained the purpose of the visit with the Administrator Judith Barajas via telephone. Administrator gave permission for Staff Roxana Aguirre to sign for this report.

A tour of the facility was conducted with Staff. The residence was set at 75 F temperature.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Resident rooms toured. LPA observed a broken door knob in resident room.

Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 11/24/25. LPA checked water temperature which measured at 119.9 F. Fire drill was last conducted 12/1/25.

Resident, medication and staff records were reviewed. Staff did not have training for postural supports, restricted health care plans and hospice. Staff had current medication and dementia training. Current first aid and CPR were reviewed.

Licensee will submit a current facility sketch.

A copy of this report with appeal rights and plan of correction was provided to the Administrator via email.