Facility Evaluation Report

On August 6, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting compliance checks following the Noncompliance Conference on May 14, 2025. LPA explained the purpose of the visit and was granted entry by Receptionist Jasmine Aguirre. Assistant Executive Director (AED) Monica Aguirre and Executive Director (ED) Melanie Washington arrived a short time later and the following pertinent documents were obtained: Staff and Resident Rosters, LIC500 Personnel Record, staff schedules, weekly water logs, Dietary Services Consultant Report, and daily and weekly audits. There are currently 118 residents on census.

At 9:00 am, ED Melanie Washington accompanied LPA Bentley on a tour of the facility. During the inspection, LPA conducted health and safety checks on residents and observed hot water temperatures measured between 98.2 and 104.5 degrees F in four out of five separate bathrooms used by residents in care. A deficiency is being cited.

Per record review of medication training, a new medication technician was hired and trained in accordance with the compliance plan. AED Aguirre stated the facility has not begun the ten hours annual refresher training required for facility staff. Medication quality assurance checks are being done daily and weekly. The dining service director performs weekly food quality assurance audits and met with a dietician on June 5, 2025. Water temperatures are checked weekly and logs are maintained. The facility has also hired a medication manager and care manager to provide oversight of resident needs and staff.