Facility Evaluation Report

On 02/25/2026 at 9:15AM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the residence to conduct a Case Management visit and to audit medications. LPA was greeted by staff, granted entrance into the residence and stated the purpose of the visit. LPA met with staff, Francisco Gramonte.

LPA completed an audit of medications for four (4) residents and reviewed both the Medication Administration Records (MAR) and the Centrally Stored Medications List (CSM). LPA observed that Resident 1 (1) was missing three medications listed on their CSM list. Resident 3 (R3) had two medications that were not listed on their CSM. Resident 4 (R4) had one (1) medication in their bubble pack, but it was not listed on the MAR. LPA did not observe physician's orders for the residents that were prescribed medications. In addition, LPA observed that prior to administering medication prescribed for the afternoon and bedtime, staff had already initialed the MAR. A deficiency will be cited.

LPA reviewed the Department's Unusual Injury Report log and it revealed that the Licensee/Administrator did not report several incidents involving the health and safety of R1. A deficiency will be cited.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and copies were provided to staff, Francisco Gramonte.