Facility Evaluation Report

Unannounced Plan of Correction visit made out to this facility on 04/09/2026 by Licensing Program Analyst (LPA) Arielle Pascua. This LPA was met by the facility staff person Mona Liza Hallman. A brief interview was conducted with the facility staff person at this time. There was on staff member present but left during the course of this visit, Shannon McGurk.

This LPA requested that she go ahead and contact the facility designated Administrator to inform them that CCL was present at this time.

The purpose of this visit was to follow up an annual visit conducted on 02/23/2026 and Two Type A violations discussed during the visit.

On 02/24/2026, LPA Pascua received an email from the licensee stating that medication retraining, as outlined in the plan of correction (POC), had been conducted. The licensee also indicated that copies of the February 2026 Medication Administration Record (MAR) were not available at the time of the LPA’s visit.

Additionally, LPA Pascua did not receive documentation of the agreed-upon medication training at the time of the visit with Licensee Nolasco. LPA Pascua subsequently requested, via email, the POC documentation and proof that the training was conducted on 02/24/2026. In response, Licensee Nolasco provided documentation showing two staff members’ signatures and the training date. However, this did not fulfill the agreed-upon POC requirements. The POC specified that the training must be at least one hour in duration and include supporting materials such as training topics, instructional content, and certificates. These documents were not provided to LPA Pascua by the POC due date. In addition, during this visit, LPA Pascua received the MAR for March 2026 and April 2026, however records reveal that documentation has not been completed to its entirety.