Facility Evaluation Report

Licensing Program Analysts (LPA)s Brian Balisi, Martha Arroyo along with Licensing Program Manager (LPM) Desaree Perera arrived at the facility unannounced to conduct an annual continuation visit. LPA's and LPM met with staff and explained the reason for the visit. Administrator arrived shortly after.

At approx. 09:35 a.m. , LPA's and LPM conducted physical plant. The following was observed:

At approx 09:45 a.m., LPA's and LPM observed Resident #1 (R1) assisting Resident #2(R2) to the restroom. Staff #1 (S1) stated R1 assists S1 with R2 due to S1 being the only one on shift since Sunday 08/31/2025.

At approx 09:56 a.m., LPA's and LPM observed insulin stored in the fridge accessible to residents in care.

At approx 10:00 a.m. LPA's and LPM observed Medications stored in Resident #3 (R3)'s room.

At approx 10:15 a.m. LPA's and LPM observed S1 administering insulin to R2.

At approx 10:44 a.m., LPA"s and LPM did not observe a sufficient amount of perishable and non-perishable food store in the fridge or the pantry closet by the front door.

At approx 10:45 a.m. LPA's and LPM did not observe a sufficient amount of PPE.