Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Ben Rosario. Manager Milagros Bucatcat arrived during the visit.

During today's visit, LPA toured the facility, reviewed facility records, observed residents in care, and spoke with staff. Review of resident records revealed that one resident did not have an initial medical assessment and multiple residents had medical assessments which were incomplete. During the tour of the facility, LPA observed multiple medications stored in the unsecured refrigerator in the kitchen as well as all resident medications stored in an unlocked cabinet in the facility kitchen. LPA spoke with Caregiver Rosario and Manager Bucatcat who stated that the kitchen is normally locked, however, LPA observed the facility kitchen door to remain open and unlocked for a majority of the visit. During the tour of the facility, LPA observed two individuals who Manager Bucatcat stated were not residents or staff. Manager Bucatcat stated that Tenant 1 (T1) was renting a room and Tenant 2 (T2) was their partner. LPA spoke with T1 and learned that T1 has been renting a room for 4.5 years and T2 has been at the facility approximately once a week for 4 months. LPA verified on Guardian that neither individual had active fingerprint clearance or association to the facility. [Manager was provided with an LIC811 Confidential Names List to identify residents, T1, and T2].