Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit. LPA met with Licensee/ Administrator Ana Duenas. Office Manager Andrew Escobar arrived shortly after. The purpose of the visit was to follow-up on items addressed during the Noncompliance Conference (NCC) meeting held on September 17, 2025.

During the NCC meeting licensee agreed to:

Hire an additional staff member within 30 days of (9/17/25) that will work as needed for oversight of record documentation, and other facility responsibilities.

Status: On 11/3/2025, Licensee Ana Duenas hired Office Manager Andrew Escobar. Licensee continues

to be the facility Administrator. Ms. Duenas stated she cannot financially hire an Administrator.

Licensee agreed to submit a written plan, update the Plan of Operation and facility sketch addressing live-in staff accommodations. If a permit for an additional dwelling unit (ADU) has been requested submit proof of documentation.

Status: Licensee stated that the 2 live-in staff, of which one was sleeping in the garage and the other in

the living room are now sleeping in former resident room #3. The room was designated as a

live-in staff room. The facility sketch was updated.

* Pending: An updated Plan of Operation that addresses physical plant changes has not been

submitted. A repeat citation and civil penalty was assessed.

1. (R1) is not currently enrolled in hospice and their bed had full bed rails,

2. A Vitamin B-12 1,000 mcg was observed unlocked in the living room and Allergy Relief Antihistamine 10 mg was observed unlocked in staff room.

Pursuant to Title 22, citations were issued.

Exit interview was conducted and a copy of the report/appeal rights were issued to Ana Duenas.