Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a plan of correction visit for deficiencies issued during the annual inspection issued on October 22, 2025. LPA was greeted and granted entry by staff. Caregiver August Rebollar called Administrator Diane Nguyen and informed her that LPA was at the facility. Administrator granted Caregiver permission to assist LPA during the visit and was available by phone.

LPA toured the facility and tested the water in the resident restroom to be at 106.5 degrees Fahrenheit thus clearing the citation 87303(e)(2) stating that water needs to be between 105 and 120 degrees Fahrenheit has been corrected.

LPA reviewed staff files and observed them to be complete with all regulatory requirements thus clearing the citation 87412(a) stating that staff files will be maintained on each employee at the facility has been corrected.

LPA reviewed resident files and observed medical assessments with all current residents in care thus clearing the citation 87458(c)(1) stating that a physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination has been corrected.

LPA reviewed documentation of a fire drill conducted with staff on November 1, 2025 clearing the citation 1569.695(c) stating that a disaster drill is to be conducted quarterly has been corrected.