Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Kimberly Malaspina.

The purpose of the visit was to document the clearance of the POC for the deficiency issued on 4/7/2025. On 4/7/2025, the licensee was issued a deficiency with a correction due date of 5/7/2025.

During today’s visit, LPA Borunda verified that the licensee corrected the deficiency regarding medication management and storage. Therefore, the deficiency 87465(h)(2) is corrected. LPA provided Executive Director with a letter of Deficiency Cleared.

An exit interview was conducted with Executive Director Kimberly Malaspina, whose signature below confirms receipt of a copy of this report, the Letter of Deficiency Cleared and the Licensee Appeal Rights (LIC9058 3/22).