Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted a Plan of Correction Visit (POC) to follow up on deficiencies cited during complaint investigation visit on 4/2/2026. Upon arriving at the facility, LPA met with Marites Jacinto, Direct Support Staff, and explained the purpose of this visit. Assistant Administrator, Marilyn Acabal, arrived thereafter.

The purpose of today’s visit is to follow up on the POCs that were due on 4/10/2026 and 4/17/2026.

The following citations were cleared today:

CCR 80023(d) Disaster and Mass Casualty Plan: Administrator provided LPA with list of dates for planned drills for the year 2026.

CCR 80023(a) Disaster and Mass Casualty Plan: Administrator provided a copy of completed plan and proof of in-service training discussing the plan with staff.

CCR 80075(g)(1)(A) Health Related Services: LPA observed a current edition of the First Aid/CPR manual and is kept in the facility with First Aid kits.

CCR 80075(f) Health Related Services: LPA was provided with proof of First Aid/CPR recertification for S3 and S4.

The following citations are being assessed for Civil Penalties – Failure to Correct:

CCR 80066(a) Personnel Records: Proof of First Aid/CPR re-certification was not present in S1 and S5’s file during record review. Administrator was unable to provide copies of re-certifications. Civil penalty assessed for $1000.