Facility Evaluation Report

( Licensing Program Analysts (LPAs) Elena Mallett and Cynthia Chan conducted an unannounced POC visit and met with Staff in Charge, Adrianne Gray regarding citations issued on 12/11/25. The purpose of the visit was to inspect the facility to ensure the deficiencies cited on 12/11/25 were corrected and were discussed. Staff Adrianne Gray stated Licensee Percy Olidan has gone to the Phillipines on a personal matter and has not been at the facility since 3:30 AM on 12/11/25. Staff Adrianne Gray stated Licensee was told about deficiencies from 12/11/25 visit.

On todays visit, LPA Mallett observed the following deficiencies have not been corrected: Per Staff Licensee stated she will handle the POCs upon return.

HSC 1569.618(c)(3) - Other Provisions (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

Based on record review, the licensee did not comply with the section cited above has 2 out 3 Staff , Staff 2 and 3, did not have a current CPR training on file and 3 out 3 Staff ( S1, S2 and S3) did not have current First Aid training on file. This affects 3 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

As of today's visit S2 and S3 did not have current CPR and First Aid training on file,On today's visit Staff was using unoccupied residents room. Civil Penalties issued on today's visit in the amount of $ 400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.