Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Care Assistant, Sister Cecelia Cuesta and Sister Magdelene Grace, Administrator and LPA explained the purpose of the visit. The facility is licensed to care for 28 non-ambulatory, of which eight (8) may be bedridden. Approved hospice waiver for 12.

The initial annual visit was conducted on 09/25/2025. During the initial visit the following seven (7) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights-Information, Planned Activities, Food Services, and Disaster Preparedness.

During today’s annual visit, the following five (5) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Incidental Medical & Dental, and Residents with Special Health Needs.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Staffing: A total of (43) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed five (5) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.