Facility Evaluation Report

On 12/11/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted a Case Management visit during their initial complaint visit (Control# 31-AS-20251202141313) and the following deficiencies were observed. LPA interviewed and conducted record reviews pertaining to three (3) residents (R1-R3) and one (1) staff member (S2).

Upon LPA’s record review, LPA observed three (3) of the three (3) residents records to be incomplete and not updated. LPA observed three (3) of the three (3) residents to be missing their Needs and Services and Pre-Appraisals. When LPA interviewed S2 and questioned how they are providing care to the residents without knowing what their care plan or needs are, S2 stated that they will review their hospital discharge paperwork and base their care from there forth.

During LPA’s record review of S2’s personnel record, LPA observed S2 First-Aid/Cardiopulmonary Resuscitation (CPR) certificate to be dated 10/12/2022 which was expired. LPA advised S2 to renew their certificate, which they agreed they would do so. LPA could also not locate any training for S2. S2 stated that they are to receive training from the Administrator. Let it be noted that S2 was the only caregiver present during LPA’s visit.