Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management Visit to the facility. LPA met with and was granted entry by staff and later met with Administrator who were informed of the purpose of the visit. At the time of the visit there were (4) residents and (3) staff present.

LPA conducted a walk through of the facility, observed residents in care, food supply, working utilities. LPA checked criminal record clearance for staff present during the visit. (1) staff was not associated to the facility, the Administrator associated the staff during the time of the visit and LPA verified the staff clearance during the time of the visit. Therefore, a deficiency was issued for not associating the staff prior to staff starting to work at the facility.

As of 1/22/2025 the facility hospice waiver has been revoked and exceptions are required to retain hospice residents. Per resident's LIC602 Physician's Reports and Administrator Interview no residents are currently on hospice services.

As of 1/22/2025 the Licensee agreed to obtain outside source training to all staff every quarter and provide proof of training documentation regarding the following topic: Basic Services, Personnel Requirements, Personal Rights, and Allowable Health Conditions and Managed Incontinence. LPA reviewed the training was last conducted in September 2025 and January of 2026 through an outside source.

No health or safety issues were observed during the time of the visit. An exit interview was conducted with staff were this report was reviewed and provided.