Facility Evaluation Report

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on August 8, 2025, during an annual inspection visit. LPA also amended the previous report to add additional information and to cite an additional deficiency that was erroneously not cited during the previous visit.

The facility was cited the following deficiencies on August 8, 2025 with the following POC dates

1569.695(c) - Emergency Drills- Type B- POC due date August 15, 2025.

87307 Personal Accommodations and Services (d)(6)- Type A- POC due date August 9, 2025.

87465 Incidental Medical and Dental Care (h)(6)- Type B- POC due date August 15, 2025.

LPA received plan of corrections by POC date. Deficiencies cleared during todays visit.

On August 8, 2025, during the tour of the home, LPA noted there was "hook & eye", metal latch outside the living room door, leading towards the outside. Note, this facility is licensed to have 3 non-ambulatory on the first floor and 1 bedridden in bedroom #3. The exit located in the living room, and adjacent to bedroom #3 is the only exit that has a ramp. LPA asked ADM why this latch was on the outside of the door. ADM asked staff S1, who stated the latch was put there because there used to be a resident who wanted to go outside a lot. ADM stated this resident no longer lives in the facility. ADM removed the metal latch during visit.

A deficiency was cited during todays visit. This report was reviewed with ADM Merclo Garcia. A copy of this report and Appeal rights were provided.