Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a Plan of Correction inspection for two deficiencies issued on May 20, 2025 during the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Maria Sangrador and explained the purpose of the visit.

LPA toured the facility to check that the deficiencies have been corrected. LPA observed an invoice for the broken medication cart. LPA observed the medication cart to be locked making it inaccessible to residents. LPA observed an in service training log discussing sharps, toxins and chemicals that should be locked at all times making them inaccessible to residents in care. LPA observed the toxins, chemicals and sharps to be locked under the kitchen sink and made inaccessible to residents in care.

Based on today’s observations the Plan of Correction has been fulfilled by the assigned Plan of Correction due date of May 21, 2025, thus clearing the Type A deficiencies CCR 87309(a) and 87465(h)(2).

An exit interview was conducted with Administrator Maria Sangrador and a copy of this report was provided at the facility.