Facility Evaluation Report

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Plan of Correction (POC) visit regarding a deficiency that was cited on 10/17/2025. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Co-Owner Henry Cruz. Administrator Linda Cruz arrived later in the visit.

On 10/17/2025, the facility was cited for no background clearance for multiple staff including Staff 1 (S1). The Departments system shows that S1 was not cleared as of today 12/19/25 and evidence shows S1 has been present at the facility routinely. The system shows that other staff mentioned on the visit from 10/17/2025 have been cleared. Due to the Department failure to review plan of correction timely, the facility will be issued another POC date to submit proof of clearance for S1.

Additionally, during today's visit, medication cart and cabinet were observed to be unlocked. Statement from Licensee revealed License regularly leaves medication cart unlocked but will occasionally lock the door of the room. On today's date, both the door of the medication room, the medication cart and the medication cabinet were unlocked. It was also observed on the facility schedule that two new employees have not been associated to the facility (S2 and S3). Licensee states that S2 has worked 3 shifts and S3 has worked multiple shifts since November 2025.

Based on findings of today's visit, LPA Strong issued an additional extension for the original POC from 10/17/2025 for S1, and issued two additional citations for unlocked medication and additional not associated staff working at the facility(S2,S3) in which an immediate civil penalty has been issued and a repeat violation penalty. An exit interview was conducted with Administrator Linda Cruz to whom a copy of this report along with LIC811, LIC421IM, and LIC421 BG were provided. Their signature below confirms receipt of these documents