Facility Evaluation Report

Licensing Program Analyst (LPA) Nadia Shahbazian conducted a Case Management Visit at the facility for the purpose of Records Review. LPA met with Norielle Lim - Care Provider. LPA spoke with Administrator Rie Santos over the telephone. Administrator stated that she is in meetings today and unable to come to the facility. Administrator designated Norielle Lim to sign the report. An entrance interview was conducted.

LPA requested copies of the Resident Roster and the current LIC 500, and any other Staff Schedule used by the facility.

LPA conducted a review of Facility Resident Records for six (6) of six (6) residents. LPA requested copies of documents including but not limited to the admission agreement, preplacement appraisal (LIC 603), all reappraisals (LIC 603A), physician’s reports (LIC 602A), functional capability assessment (LIC 9172), identification and emergency information (LIC 601), appraisal/needs and services plan (LIC 625), centrally stored medication and destruction record (LIC 622) and the Medication Administration Record (MAR) if any. In addition, LPA requested admission documents for all residents currently receiving hospice services.

Per telephone call, facility Administrator agreed to scan and email the requested documents to the LPA by close of business on Tuesday, 4/8/25. An exit interview was conducted and a copy of the LIC 809 provided.