Facility Evaluation Report

Unannounced Plan of Correction visit made out to this facility on 01/29/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Pedro Pancho. A brief interview was conducted with the facility designated Administrator at this time.

The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 10/31/2025. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 10/31/2025:

A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

All facilities shall maintain a fire clearance approved by the city, county , or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county , or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Bedridden persons

A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.