Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction (POC) visit from subsequent annual visit conducted on 12/01/2022. LPA met with DSP Sir Ivan Sison and explained the reason for the visit. LPA was later joined by Administrator Rhea Ortiz-Luis.

During today’s visit LPA observed the following:

3x4 cemented gap missing tile flooring in middle of client bathroom was repaired and new tile flooring was placed. LPA issued deficiency citing 80087(a) during the required annual visit on 12/01/2022, with a Plan of Correction (POC) due date of 12/15/2022. Administrator Ortiz-Luis claims she emailed LPA proof of new flooring in client bathroom, however, LPA did not receive such email prior to today’s visit nor a request for extension. Administrator Ortiz-Luis did send an email on 12/23/22 at 9:21am with a photo attachment of new tile flooring in client bathroom, after LPA arrived at the facility and observed the new flooring. LPA will assess civil penalties.

Construction debris including glass, bricks, and a folding table were observed by side of facility walkway. LPA issued deficiency citing 80087(c) during the required annual visit on 12/01/2022, with a POC due date of 12/15/2022. Administrator/Licensee did not correct deficiency nor submit proof of correction to this licensing agency by the POC due date. Folding table was moved to garage during the visit, glass and bricks were removed during visit. LPA will assess civil penalties .