Facility Evaluation Report

On 07/09/25, around 01:30 PM, Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analyst (LPA) Talwinder Bains, Licensing Program Analyst (LPA) Lavinia Muscan were present for a Non-compliance Conference with Licensee / Administrator Nelson Jacinto which was held in-person in the office.

This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. Since last office meeting with facility on 07/31/24, the facility has been issued 9 A citations, 6 B citations, civil penalties and repeat civil penalties $4,850 were issued.

Substantiated Complaints, case management visits and other visits include allegations in the following areas:

- Not providing timely medical care including resident’s death, Residents Personal Rights, Issues with food services and physical plant, no activities for residents and various other areas related to residents’ health and safety

The licensee shall submit the following by AUGUST 1, 2025:

Develop and implement new protocols for timely medical response; supervision and fall reduction.

Submit Training, policies, management oversight to ensure care staff is aware and familiar with the needs of the residents and when to call 911.

Create activities based on resident's preferences.

Cups should be available at water station at all times for residents.

Conduct mandatory training for all staff in the above areas.

Plan how food will be available to residents.

Implement internal audits and increase administrative oversight.

Conduct mandatory training for all staff in the above areas

Licensee shall hire a qualified administrator by 08/01/25. Compliance plan documents shall be submitted to CCL by: 07/23/25 COB; Fully implement plan with documentation by 08/09/25. Provide proof of staff training completion. Submit all documents to LPA Bains via email. The licensee agreed with the drafted non-compliance plan as outlined in LIC 9111. No citations were issued today. An exit interview was conducted, and a copy of this report was provided to the licensee.