Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent annual inspection visit on 10/18/2025 and was greeted by Gina Alvarez- Business Office Director and discussed the purpose of today’s visit. LPA Ramirez conducted initial annual inspection on 10/02/2025. Administrator Adriane Runge arrived shortly after to assist. LPA Ramirez identified herself and explained the purpose of the visit.

Operational Requirements: The fire clearance is approved for ninety-seven (97) non- ambulatory resident, of which seven (7) may be bedridden. This facility may retain no more than fifteen (15) hospice residents. There were eight (8) residents under hospice care, during annual inspection.

Staffing: Administrator Certificate (7003384740) for Adriane Runge with an expiration date of 06/05/2027 was observed. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the six (6) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6) out of the six (6) personnel record reviewed.

Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 09/27/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided.