Facility Evaluation Report

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Legal/Non-Compliance visit at 9:48AM. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance as discussed in a Non-Compliance Conference on 12/15/2025. The LPA met with Assistant Administrator (AA) Riza Vitug and Executive Director (ED) Lito Vitug arrived at 11:08AM. Entrance interview conducted.

During today’s visit, the LPA and AA conducted a physical plant tour at 10:02AM to ensure there were no health and safety hazards. The following was observed:

LPA Huynh observed a total of sixteen (16) randomly selected resident rooms, each with a private restroom, on the first and second floor and interviewed nine (9) residents. Interviews with residents did not reveal any immediate concerns and they were all generally happy and appreciative of the care provided by the facility. Resident rooms obtained all required furniture and had sufficient lighting. Restrooms were observed to have non-slip mats and grab bars. Hot water temperature was measured and six (6) out of eleven (11) restroom sinks measured above 120 degrees F, which is not within the required range. The ED explained that the facility installed a new boiler a few months ago with follow up inspections, which may have been the cause of the temperature spiking. The Maintenance staff stated that the boiler’s temperature was set to 120 degrees F and that they would lower it.