Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction (POC) clearance. LPA Lopez identified herself and was granted entry by Licensee Victoria Legaspi. LPA met with Licensee Legaspi and discussed the purpose of today’s visit.

On 5/19/25, Licensee was reissued citations for Plan of Operations and Reporting Requirements with a due date of 05/26/2025. A plan of correction (POC) was jointly developed with the licensee Legaspi. During today’s visit, LPA confirmed that the licensee did not have their POC for their Plan of Operations and a civil penalty will be issued during today’s visit. The licensee was able to produce the POC for Reporting Requirements, during today’s visit. A civil penalty is still being issued for the time elapsed between 5/26/25 through 05/28/25.

On 4/24/25, Licensee was issued deficiencies for not having fire drills and evacuations chairs, due 05/23/25. A POC was jointly developed with licensee during the time of the visit. During today’s visit, LPA confirmed that the licensee did not have their POC cleared during today’s visit. Civil Penalties are being issued for the deficiencies that were not cleared.

Also, on 4/24/25, the Licensee was issued multiple deficiencies regarding staff training, residents' functional capabilities assessments, residents' pending medical assessments, activities for residents, and facility financial records.