Facility Evaluation Report

Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassandra Mikkelson arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 08/06/2025 during a case management visit. LPAs met with Staff Dillon Williams and explained the purpose of the visit. Staff notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist and sign the report during today's visit.

On 08/06/2025, LPA cited the facility on CCR 87405(a) and Licensee agreed upon a POC Due Date of 08/20/2025 Licensee will update LIC500 and have themselves on the schedule three days a week at the facility. Licensee did not ensure that the POC was corrected upon Due Date of 08/20/2025. LPA will be assessing a Civil Penalty of $100/day from 08/21/2025 to 08/26/2025 for this violation and will continue to accrue until POC is corrected.

Additionally, during visit LPAs conducted a medication audit for four (4) residents.

Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date.

Exit Interview was conducted. A copy of the report and appeal rights were left at the facility.