Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Roberts, Resident Care Coordinator and Allison Lopez, LVN. LPA stated the reason for today's inspection was to clear (2) Plan of Corrections.

LPA discussed the Plan of Correction due on/around February 2025 which included documentation of scheduled carpet cleanings. LPA obtained documentation during today's inspection that spot cleaning was done, as needed, prior to carpet cleaning machines being rented to clean the entire community on August 26, 2025 and on September 16, 2025. In October 2025, a brand new commercial carpet machine was purchased and cleaning began to be scheduled on a monthly basis.

LPA toured the interior of the facility and observed the carpet flooring. LPA observed the carpet to be clean with no noticeable stains and to have no tears or tripping hazards. The facility did not have any odors present throughout. LPA observed staff to be gathering residents in the dining room before dinner.

LPA discussed the Plan of Correction due on/around December 3, 2025 involving in-service training with all staff to discuss following protocols when there is change of condition, including contacting the resident's primary care provider for direction. LPA was provided with documentation of the material covered and attendees for a training conducted on December 1, 2025.

A Letter of Deficiency Citations Cleared was provided for each Plan of Correction (2) cleared, along with this report. There are no deficiencies issued in this report.