Facility Evaluation Report

On 11/07/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Jessica Playa, Executive Director. The facility has an approved hospice waiver for (10) with (24) residents currently receiving hospice services, and an approved fire clearance for (10) bedridden residents, with currently (4) bed bound residents in care. There is total of (7) residents receiving home health services.

The facility was observed to be clean with the passageways being free of any obstructions. The medications, chemicals and sharps were observed to be locked an inaccessible to residents in care. The fire extinguishers were last serviced on 03/19/25. The emergency disaster drills are being conducted on a quarterly basis with the last drill being on 10/27/25. The hot water was tested and was in within regulatory limits ranging from 105.1-114.6 in assisted living and 105.3-108.1 in memory care. The smoke and carbon monoxide detectors were tested and found to be operable.

A records review was conducted, the facility annual fees were observed to have been paid, and for the governing body to be in good standing. The resident files were observed to have medical assessments and, and completed admissions agreements. The staff files reviewed were observed to have criminal record clearance and to be associated to the facility. The staff files reviewed were observed to have been completed initial and ongoing training, however there was an insufficient number of staff to have a staff with valid Cardio Pulmonary Resuscitation certification on the premises at all times. deficiency cited.