Facility Evaluation Report

On 12/19/2025, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to address a deficiency found during a complaint investigation. LPA met with Business Office Manager Nicole Anguiano, Administrator Teresa Mapilis and Wellness Director Marielle Figueroa who were informed of the purpose of the visit.

During investigation of complaint control 18-AS-20240619104115, LPA reviewed a Service Plan for Resident 1 (R1) dated 03/19/2024. LPA also reviewed Unusual Incident/Injury Reports (LIC 624s) reporting R1's unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 where R1 was reportedly found on the floor inside and outside of the facility. The reports documented 911 was called each time, and each time R1 was transported to the hospital for further evaluation. The reports also indicated R1’s responsible party and primary care physician were notified, and LPA confirmed they were submitted to Community Care Licensing timely. BOM Anguiano reported she was unable to find documentation of an updated reappraisal noting a plan to address R1's unwitnessed incidents noted above to prevent future incidents. Per BOM, the only Service Plan for R1 on file is dated 03/19/2024. As a result, the facility will be cited. An exit interview was conducted and a copy of this report, LIC 809-D, Confidential Names list (LIC 811), and Appeal Rights were reviewed and provided to Wellness Director Figueroa.