Facility Evaluation Report

On March 11, 2025 at 9:50am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on July 1, 2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Angelita Maravillas and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

At 10:05am, LPA and Licensee conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. In bedroom #2 LPA noted two electrical outlets with no faceplates, leaving wires accessible.

LPA and Licensee conducted a review of the facilities Centrally Stored Medications and Destruction Records (CSMDR) and the centrally stored medications for all three residents in care. During the review LPA and Licensee noted Resident #1 (R1) has a tube of triamcinolone 0.1% cream not logged on R1's CSMDR. Resident #2 (R2) with a bottle of quetiapine 25mg, pharmacy label states quantity thirty (30), instructions take one tablet by mouth every day, a physician order dated 11/12/25 states take one tablet by mouth twice daily and the CSMDR states this bottle was started November 2025 with no day noted. Had the medication been given as prescribed the medication from this bottle would have run out in fifteen days but a count of the pills in the bottle revealed eighty-six (86) pills, Licensee stated the reason there were more pills in the bottle