Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Annual Continuation. The is a continuation of the annual inspection that was conducted on 11/20/2025, during which only the physical plant was inspected due to time constraints. LPA met with Administrator (ADM) Michael Rosete. Licensee Lilette Rosete joined the inspection at approximately 3:15PM.

During today's visit, LPA reviewed 3 resident files, 3 staff files, and 3 residents Centrally Stored Medication and Destruction Records (CSMDRs). During review of Resident R3's CSMDR with the ADM, LPA observed R3's centrally stored log was not updated. ADM updated R3's medications on the CSDMR during the visit. LPA advised to ADM to ensure staff are documenting and updating residents centrally stored logs in a timely manner. A Technical Assistance was issued, see LIC9102.

LPA reviewed the facility's emergency drill logs. The facility's last emergency drill was conducted on 9/2/2025.

No deficiencies were cited during today's visit. A Technical Assistance was issued, see LIC9102 for more information. An Exit Interview was conducted with the ADM and a copy of this report was provided.