Facility Evaluation Report

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiencies noted on 12/29/2025 during an annual visit. LPA met with staff and explained the reason for the visit. LPA spoke with Administrator Ralph Estanislao over the phone.

On 12/29/205 LPA Gonzalez conducted an annual visit and noted the following deficiency:

Type B section cited 87608(a)(3) Postural Supports

(a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident ...Postural supports may be used under the following conditions. (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

Based on observation and record review, the licensee did not comply with the section cited above R1, R4 and R5 did not have a order for bed rails.

Deficiency was not cleared by POC due date. *Civil penalties were noted for failure to correct.*