Facility Evaluation Report

Licensing Program Analyst (LPA) Evelin Rios made an unannounced case management visit to this facility. LPA met with the house manager and explained the reason for the visit is to inform the Licensee that the licensing fees are past due. LPA was also at the facility to follow up on the status of a fire clearance request and hospice waiver request.

During today’s visit, LPA was provided a receipt confirming that payment for the past due licensing fees, totaling $1,484.00, was paid today.

On 04/14/2026, the facility was cited because two (2) of six (6) residents identified as non-ambulatory were residing in bedrooms approved only for ambulatory residents. During the same visit, the licensee had failed to submit a waiver request to increase their hospice capacity from three (3) to four (4), despite retaining a fourth terminally ill resident. Today, at 3:35 p.m., LPA spoke to Anne Gregorio, the Licensee on the telephone. LPA informed the licensee that a waiver/exception request was returned to the licensee requesting further clarification regarding hospice. According to the Licensee one (1) of the four (4) residents receiving hospice services has a scheduled reassessment as they may no longer be recertified to receive hospice services. They will still submit a waiver to the department to increase the Hospice Waiver. The licensee also stated they are in contact with the Fire Inspector and a final fire inspection visit is pending. Since the 04/14/2026 visit two (2) residents have left the facility and two (2) new residents were admitted. Residents are currently placed in appropriate ambulatory and non-ambulatory bedrooms. No immediate health or safety issues observed during today's visit.

No deficiencies cited. Exit interview conducted and a copy of this report provided to the House Manager.