Facility Evaluation Report

Licensing Program Analyst (LPA) Daiquiri Boyd and Licensing Program Manager (LPM) Shawna Doucette arrived unannounced to conduct the Annual inspection. LPA explained the purpose of the visit and allowed entry into facility office by care staff. Staff called Administrator, Nancy Montiano (AD) who spoke with LPA and AD stated that she was sick and could not make the visit due to illness. Office Assistant (OA) Yvonne Aggasid would be available to assist LPA on this day.

Facility tour and inspection revealed the following:

LPA/LPM requested Infection Control, but document could be produced. LIC610 Emergency Disaster Plan for Residential Care was posted and signed off 2/27/2024. LIC610D was reviewed and found to not have complete information. Administrator Certificate expired 6/15/2025, online review of certification shows it was submitted 6/9/25 and still shows pending.

LPA/LPM reviewed 3 client files. Client files were found to be missing updated Medical Assessments, some files were missing re-appraisals, elderly clients were missing correct LIC602A, files were missing restricted health care plans.

R1 had a medication that was found to be expired. LPA/LPM located a home health folder for R1 with resident information inside, no care plan was found in R1 file. LPM called home health in regard to the file and found that R1 was on home health 2/3/26 to 2/25/26 after being released from the hospital for wound care. For R1, caregiver/office staff had no knowledge that R1 was on home health or that R1 had wounds.

R1 and R2 had no restricted health care plan for existing condition. R1 and R2 did not have reappraisals on file. Last LIC602 was dated in 2023 for 3 out of 3 residents. 27 out of 52 residents were over the age of 60 and do not have the correct LIC602A on file. There is no Age Exception on file.