Facility Evaluation Report

Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday March 18, 2026, to conduct the unannounced annual inspection. LPA met with staff Neha Sharma and explained the purpose of the visit. Staff called the licensee, Jonathan Gallegos who indicated he was unable to come to the facility during today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and LPM reviewed resident (1) and staff (2) files. The resident file was missing a reappraisal. LPA only observed the initial appraisal which was completed upon move-in. During the staff file review, LPA observed S1 missing current CPR certification. S2 missing current first aid certification and physical.

During a medication audit, LPA and LPM observed the following: medications which were prescribed for residents who moved out in January were still at the facility. On R1's MAR, potassium chloride was crossed out to indicate it was discontinued, however there was not a discontinued order on file. LPA and LPM observed two medications which were in R1's room, not locked up and accessible to the resident.

See 809-D for citations issued during todays visit.

Exit interview conducted. A copy of this report and appeal rights were provided to the facility.