Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual inspection. LPA met with Administrator Mariza Chua and disclosed the reason for the visit. During today's visit, LPA reviewed the medication and ensured that medication records were properly documented. LPA also reviewed the files of residents and personnel. LPA observed that the Staff#1 (S1) employee file is missing the following forms: LIC 501, LIC 503, and LIC 508. Staff#2(S2) employee file is missing the forms LIC 501 and 508. In addition, LPA observed that Resident#4 (R4) was hospitalized on 08/18/25 and Licensee/ Administrator did not submit Unusual Incident Report LIC 624. Administrator stated that they will provide the required documents promptly.

Exit interview conducted, citations issued, appeal rights given and copy of this report delivered.