Facility Evaluation Report

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Dory Lacwasan. and the purpose of the inspection was discussed. Administrator (AD) Cherry Aguila was contacted by phone and arrived at approximately 3:00 p.m.

LPA is following up regarding deficiencies previously cited on June 20, 2025, during facility's annual/required inspection. Deficiency 1569.625(b)(1) was cited due to one of two staff records not containing documentation consisting of completed 20 hour required staff training. Deficiency 1569.69(a)(2) was cited due to two of two staff files not including documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training or instruction. Deficiency 1569.695(c) was cited due to emergency drills not being conducted. Deficiency 87307(a) was cited due to staff residing at the facility and spending the night on the living room couch. Deficiency 87307(a)(2)(C) was cited due to a bathroom located within a resident's bedroom being used as the staff bathroom.

AD provided LPA with completed 20 hours, including six hours specific to dementia care, four hours specific to postural supports, restricted health conditions, and hospice care for staff via email on August 15, 2025. On the same email, AD provided documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training instruction. On July 7, 2025, AD provided LPA with documentation for disaster drill held on July 2, 2025, it included the date, the type of emergency covered by the drill, and the names of staff participating in the drill via email.