Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240328095338). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with Administrator Izhak Illouz and Licensee Arlene Ceballos and explained the reason for the visit.

During initial visit, LPA conducted a tour of the physical plant. At 10:28 a.m., LPA requested to review facility files, employee’s roster and residents’ files. Additionally, at 10:45 a.m., LPA obtained and reviewed copies of pertinent documentation relevant to the investigation. Between 11:20 a.m. and 12:54 p.m., LPA conducted interviews with facility staff, Administrator, and residents.

During today’s visit, the LPA conducted a brief physical plant tour, to ensure there are no health and safety concerns.

During the Department’s investigation, the following deficiencies were observed:

A review of the staff schedule for March and April 2024 was conducted to assess the allocation and coverage of staff. The schedule was organized into three columns. Each column detailed the coverage for three of the facilities operated by the Licensee, however, shift schedule was not noted. Interviews with the administrator indicate that the facility provides appropriate care for residents during the night shift. According to the administrator, staff conducts constant checks on residents throughout the night.