Facility Evaluation Report

On 4/29/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit was to conduct a Case Management visit the facility to discuss Technical Assistance Program (TSP) consultation services provided to the facility. LPA met with the facility administrator Sera Nakalevu. The current census is 14 with 3 facility staff present.

On 3/17/2026 the facility completed consultation services with the Technical Assistance Program (TSP). LPA reviewed the TSP engagement summary with the facility administrator. The following focus areas were identified during the consultation

· Recordkeeping- TSP discussed and provided training resources and recommendations including Personnel Records Guide, Resident Records Guide, Personnel/Resident File Review Checklist, Daily Resident Log, RCFE checklist

· Physical Plant- TSP discussed training resources and recommendations to support continued compliance, including monitoring and oversight of the physical plant, conducting internal audits for identifying and resolving physical plant issues.

· Personal Rights- TSP discussed Person-Centered care and provided the following resources and training. Personal Rights (RCFE) tool to assist the provider in understanding resident personal rights, and Personal Rights Self-Assessment Guide to assist providers as they perform periodic self-assessments of the facilities.