Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Juliane Cruz.

The purpose of the visit was to verify if the two deficiencies issued on 6/19/2025 had been corrected. On 6/19/2025, the licensee was issued a deficiency of regulation 87615(a)(2) with a correction due date of 6/27/2025 and a deficiency of regulation 87465(e) with a correction due date of 7/7/2025. As of today’s date, 7/15/2025, the Department had not received proof of correction for either deficiency. According to Administrator Cruz, POC paperwork had been faxed to the Department on 6/27/2025 and 6/30/2025, however there were issues with the fax machine and LPA Borunda did not receive the POC documents.

During today’s visit, LPA Borunda reviewed resident and staff paperwork. Review of Resident 1's paperwork revealed that R1 was admitted to hospice services on 6/26/2025, which means that an exception request for R1's prohibited health condition is no longer required. Therefore, deficiency 87615(a)(2) has been corrected. Review of staff training paperwork revealed that staff received medication training on 6/26/2025. Therefore, deficiency 87465(e) has been corrected. LPA provided Administrator with letters of Deficiency Cleared for both deficiencies.

An exit interview was conducted with Licensee Tonya Weaver via telephone and Administrator Juliane Cruz, whose signature below confirms receipt of a copy of this report, the Letters of Deficiency Cleared, and the Licensee Appeal Rights (LIC9058 3/22).