Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola and Regional Manager Reyna Lacey met with the licensee, Mary Martin in office in order to follow up on Plan of Corrections (POCs) that were previously agreed upon. LPA conducted records review and interviews.

The following deficiency was corrected and POC was received:

A deficiency was cited for 85064(b) for not having a certified administrator, the licensee agreed to submit their renewal for Administrator’s certificate and designate a qualified administrator to the facility by the POC due date of 02/14/2025. Based on interview with licensee and record review of the Department's website pending renewal list for Administrator's Certificates, the licensee's renewal was received on 03/25/2025. Therefore, the POC has been met and the deficiency has been cleared.

The facility was cited for 80088(e)(1) for hot water temperature not measuring within regulations. The temperature was measured at 138.5 F in the client bathroom. The POC was for the staff to send proof of water temperature within the required range by POC due date 02/12/2025. On 3/31/2025 the licensee send proof to the LPA that the hot water was adjusted, therefore the POC has been cleared.

The following deficiency were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted: