Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon conducted a Case Management Annual Continuation visit. LPA met with Rachelle Tellez and explained the purpose of the visit.

LPA De Leon met Administrator at Centralized location for the Rose Group to conduct the file review for the residents and staff. LPA returned to complete the annual file review.

Staffing: The facility currently employs 15 staff and 3 Administrators. Staff records are kept confidential. The 5 files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Criminal Record statements. Administrator Certificate for Roxandra Administrator of record expires 08/30/2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff had 20 hours of annual training completed for all subjects/topics and hours for 2024-2025. Newly hired staff have 40 plus hours of initial training for 2025. Training records are up to date.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physician’s reports Pre-appraisals, Appraisals Needs and Services Plan, and Emergency and ID forms, all forms were legible and records are kept confidential.

Exit interview conducted and copy of report printed for Backup Administrator.