Facility Evaluation Report

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Staff Gallegos Luis. Administrator Brandon Marquez and Licensee Sandy Zhao were contacted and informed of the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Hospice waiver for six (6). During today’s inspection there were four (4) residents in care.

LPA with staff toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms did not contain a chair. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. Review of residents’ Medication Administration Records (MAR)s revealed that Resident #1 (R1) had not received one of their medications since December 3, 2025, although the physician’s order prescribed the medication to be given daily. Interviews revealed that the medication was being given as needed, as a PRN, rather than being given as prescribed. No pools or bodies of water exist on the premises. Per Licensee Zhao, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.