Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of citing deficiencies observed during the initial investigation for complaint reference 22-AS-20240205155235. During the visit, LPA toured the physical plant of the facility in the company of facility administrator Rico Mico. LPA also requested and obtained relevant resident and staff records which were reviewed during the visit.

Based on records reviewed and observations made, two type A citations and three type B citations are being issued at this time based on the following items of non-compliance:

- Toxic substances are observed to be left accessible to residents in care, in spite of the presence of multiple residents with confirmed dementia diagnoses.

- Resident records are observed to be missing signatures or physician reports for three of the six residents currently admitted.

- Two residents are observed to have beds equipped with full bed rails despite not having been admitted to hospice.

- One resident is diagnosed with a Prohibited Health Condition for which no hospice placement has been initiated, nor any exception has been sought.

One Technical Assistance Advisory Note is additionally issued due to the presence of a staff member with a valid background clearance but no staff association in Guardian on the premices.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.