Facility Evaluation Report

On 7/16/2025 at 3:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a case management visit aligned with a complaint visit on the same day. LPA met with Backup Administrator Ivan Palominos and explained the purpose of the visit.

During a recent complaint investigation LPA noted during a record review and interviews that Client #1 (C1) missed a follow-up podiatrist appointment in April 2025 due to staff not referring to the physician visit summaries. LPA interview with Staff #1 (S1), who schedules all client medical appointments revealed they have access to but do not refer to the physician visit summaries provided by the physicians, stating the reports are usually posted to the website a few days after the appointment. LPA record review also revealed the most recent reappraisal dated 11/21/2024 does not mention C1’s foot care needs or their ongoing skin condition that causes C1 to be itchy. LPA interviews with staff revealed an updated reappraisal had not been completed as of 7/2/2025. LPA discussed with Backup Administrator and S1 the importance of reviewing all physician provided documentation/orders, updating reappraisals with each change of condition, and communicating this to the care staff.

In accordance with Title 22 Regulations, deficiencies were cited today.

Exit interview conducted, deficiencies cited on LIC809-D, report, and appeal rights given.