Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne and Long-Term Care Ombudsman Diane Torres arrived to the facility at 09:57 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 10:50 AM. Entrance interview was conducted and the reason for the visit was explained.

The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 02/18/2026. During today’s visit, the LPA and LTCO conducted a physical plant tour, conducted a file review for one (1) resident, interviewed three (3) residents, and interviewed the Administrator between 10:02 AM and 12:00 PM.

On 03/12/2026 Community Care Licensing Division (CCLD) received a self-reported incident report regarding an incident that occurred on 02/18/2026. LPA interviewed the Administrator and asked why the reports were not submitted to CCLD in a timely manner. Administrator explained that they waited to submit the incident report because they were waiting to see if the resident would be returning to the facility. LPA informed Administrator that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident. Administrator confirmed that they are aware of the reporting requirement and agreed to submit a written statement confirming that they will submit all future incident reports to CCLD within the required timeframe.