Facility Evaluation Report

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Legal/Non-Compliance visit at 11:44AM. 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 Executive Director (ED) Lito Vitug. Entrance interview conducted.

During today’s visit, the LPA and ED conducted a physical plant tour beginning at 12PM to ensure there were no health and safety hazards. LPA Huynh observed a total of six (6) resident rooms, each with a private restroom, on the first and second floor and interviewed four (4) residents and one (1) family member. Interviews with residents did not reveal any immediate concerns. Resident rooms obtained all required furniture and had sufficient lighting. Restrooms were observed to have non-slip mats and grab bars. The dining room was observed to be in compliance, with residents visibly enjoying their lunch.

Medication review began at 12:42PM. Two (2) resident medications were reviewed and observed to be in compliance. The LPA observed accurate centrally stored records and refusal communication logs.

Five (5) resident records were reviewed at 1PM. Records were reviewed for but not limited to care plans, admission agreements, and consent forms. All records were in order, however the LPA reminded the ED to ensure dates and signatures are documented on all care plans.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.