Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 10/24/2025 during the required annual inspection conducted by LPA Tea. LPA was greeted and granted entry by facility staff. Administrator (AD) Marilou Leal arrived shortly to assist with the visit and explained the purpose of the inspection.

LPA Tea toured the facility to check the deficiencies that have been corrected with the administrator. LPA checked the stove top burners and they are properly working and light up. LPA inspected the bathroom and observed the broken mirror wall was dismantled and replaced with a new mirror. The wall in the bathroom was repainted. LPA notice the new PUB475 poster in the front entry way. LPA Tea will periodically check up on the facility to ensure compliancy.

Based on LPA Tea's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due date, thus clearing the Type B deficiencies CCR 87468(c)(2)(A ) and 87303(a) .

An exit interview was conducted with Administrator Marilou Leal and a copy of this report was provided to the facility