Facility Evaluation Report

Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 10/17/2025 to conduct an unannounced Plan of Correction (POC) visit. LPA met with Administrator Aliti Waqalala and explained the purpose of the visit. The purpose of this visit was to verify the plan of correction that was required to be completed on 10/08/2025 for deficiencies that were previously cited on a prior visit conducted on 10/07/2025. During today's visit, LPA conducted a brief tour of the facility. The current census was 10 with 2 facility staff.

During today’s visit, LPA Lee toured the facility and observed 3 residents in the common area watching television, while 7 residents remained in their rooms in bed. No odors related to incontinence were detected during the visit. A Walmart delivery consisting of 10 bags of groceries and household supplies was observed. Fresh fruits such as pears, bananas, oranges, plums, avocados, and red apples were observed available on the kitchen counter for residents. Additionally, LPA Lee observed a sufficient supply of food, including at least seven days’ worth of non-perishable items and two days’ worth of perishable goods. LPA Lee inspected and observed that the deadbolt on the front door had been removed. The door is now equipped with a single-action lock that can be opened from the inside, in compliance with fire safety regulations.