Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management Deficiencies Visit. LPA was greeted and granted entry by Administrative Designee (AD) Teresa Hernandez Celaya at 11am and explained the purpose of the visit.

The facility is a single-story five bedroom, two bathroom home with an approved fire clearance of four non-ambulatory and a capacity for six residents in care. The facility has a hospice waiver for four residents. Currently there are three residents in care with one resident receiving hospice services. The facility is currently undergoing a Change of Ownership (CHOW) though the Centralized Applications Bureau (CAB). The Administrator (AD) and Administrator Designee recently had a consultation with the Department's Technical Support Program (TSP) on March 3, 2026.

LPA reviewed three of three resident files and three of three staff training and fingerprint records. Three of three residents had bed rails without physician's orders. AD was informed to obtain physician's orders for bed rail orders and that bed rails must be removed since they are considered to be restraints. A Type A deficiency will be cited. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on February 24, 2027.

During the visit LPA toured the facility and observed the facility retained a minimum of two days perishable and seven days of non perishable food on hand. Medication storage and sharps and knives were secured.