Facility Evaluation Report

Licensing Analyst Program (LPA) Antonia Alvizar-Ettima conducted an unannounced subsequent visit at the above address to issue citation from 11/05/25 Case Manager visit. LPA met the House Manager granted entry. Later, Administrator joined today's visit.

On 11/5/25 visit In conjunction with unannounced complaint # 31-AS-20251030121001 visit to the facility.During inspection at 10:15a.m. LPA Alvizar-Ettima and Staff #1 (S1) tour the facility and observed that medication cabinet, sharps and toxic chemicals drawer were not locked during inspection. Staff #1 (S1) opened the medication cabinet without using a key. S1 stated that there was no key in the facility to lock the medication cabinet because Administrator took the key. LPA also observed that toxic chemicals were stored in an unlocked kitchen sink cabinet and that sharps were accessible in an unlocked drawer. S1 demonstrated that the drawer and cabinets were unlocked without the use of locking devices. S1 was unable to demonstrate proper use of the locking mechanisms for sharp and toxic chemicals. S1 indicated that the medication and chemical cabinet are “usually locked”, but were unlocked during the visit. LPA asked S1 whether they were trained in the use of locking devices. S1 stated yes they were trained but have not been locking or monitored that they were locked. At approximately 10:45a.m. Administrator confirmed that all staff will be re-instructed on secure storage of medication, sharps, and cleaning supplies. Administrator also illustrated that medication cabinet had a key and confirm they took the key with them.

Based on observation and interviews it was concluded that facility failed to ensure that medication, sharps, and toxic chemicals were stored in locked areas inaccessible to residents.

Deficiencies will be cited and recorded on LIC809D. .

Exit interview conducted. Copy of report, and appeal rights issued.