Facility Evaluation Report

On 05/28/25, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced. LPAs met with Administrator Irene Nepomuceno and explained the purpose of the visit. LPAs conducted a case management visit to follow up on items after facility's visit from 05/01/25.

: Department cited facility on 05/01/25 for staff, S1 was working at the facility on 05/01/25 and civil penalty of $500.00 was issued. Record review and staff interview indicated that facility allowed S1 to reside/present at facility after 05/01/25 which is a repeat violation 87355(e), therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.

:Residents medication closet was found to be open and medications were accessible to residents in care Department assessed penalty for $100.00 per day from 05/16/25 till date (total - $1300.00) since facility did not fulfill POC requirements which were due on 05/16/25. It should be noted that Department will assess future penalties for $100.00 per day till facility comply with POC requirements.

: LPAs observed the facility to have a door stopper propping open the fire door in the hallway which is repeat violation from 05/01/25 visit, therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.

: Facility could not provide any paperwork related to staff, S1 when asked for department audit, which is a repeat violation of regulation 87412(f),therefore repeat citation was issued. Immediate civil penalty of $1000.00 was assessed today.

As a result of today’s visit deficiency was cited as indicated on LIC809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

Exit interview conducted and a copy of the report, LIC809G and appeal rights was left at the facility.