Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 05/23/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the inspection. Administrator (AD) Tin Le arrived shortly to assist with the inspection. LPA toured the facility to check if the deficiencies had been corrected with staff. LPA observed corrections and reviewed documents. The following deficiencies were corrected:

CCR 87309(a) - cleaning supplies were locked away during inspection on 05/23/2025

CCR 87412(c) - Staff 3 (S3) completed new hire training on 06/04/2025 using a third party service

HSC 1569.625(b)(2) - Staff 1 (S1) completed annual training on 05/30/2025 using a third party service

CCR 87465(a)(6) - In service medication administration training was provided by hospice nurse

CCR 87465(h)(2) - Medication cabinet lock was replaced and now functional

CCR 87608(a)(5)(B) - Full bed rails were removed for resident 2 and replaced with half rails with orders

CCR 87207 - Licensee signed a statement of acknowledgement with regards to falsifying records

CCR 87405(a) - Licensee has designated a qualified back up Administrator for the facility

CCR 87507(l) - Personal Rights document signed and placed in resident 3's file.

HSC 1569.695(a)(2) - Emergency water was purchased for facility.

HSC 1569.695(c) - Disaster drills were completed on 05/30/2025