Facility Evaluation Report

On 6/16/2026 at 9:10am, 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 7/1/2025. 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.

LPA and Licensee toured the facility for health and safety concerns. LPA tested the hot water at 109.8°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility had no obstructions in hallways, doorways or exits.

LPA and Licensee conducted a medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records(CSMDRs). At 10:16am LPA observed a physician order dated 3/30/2026 for Resident #1 (R1) that stated memantine hcl 10MG take one tablet by mouth daily. The facilities medication administration record(MAR), CSMDR, and the medication bottle for R1 all state memantine hcl 5mg take one tablet by mouth daily. The Licensee states they over looked the dosage of 10mg on the physician order and that they have been giving R1 one 5mg tablet once daily. The Licensee called the physician for clarification and received an updated order during the visit. At 10:55am the LPA noted a physician order for Resident #2 (R2) stating seroquel 25mg take 1-2 tablets by mouth at bedtime as needed for agitation/sleep disturbances. R2's MAR for June 2026 indicates R2 has received seroquel 25mg twice daily at 8:00am and 4:00pm. The Licensee states R2 typically goes to bed between 6:00pm - 7:00pm.