Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Stephanie Silva Santos.

The purpose of the visit was to follow up with two Unusual Incident/Injury Reports (IRs) submitted by the facility. The first IR was submitted to the department on 07/08/2025. The IR reported that on 07/08/2025, the facility Quality Compliance (QC) Department informed Administrator Stephanie Silva that it will need to conduct three investigations after a staff reported allegations that staff pull resident R1's hair, throw items at R1, and encourage R1 to eat raw onions.

The second IR was reported to the department on 07/13/2025 and reported that at 2:00 AM on 07/13/2025, staff did not assist R2 in the self-administration of medication M1, resulting in R2 missing the dosage window for M1.

During visit, ADM stated that due to company policy, ADM would not be able to provide the internal investigation until QC has completed the investigation. LPA Marrufo requested that the internal investigation be submitted to the department once it is completed. ADM stated that one of the staff involved has resigned from the facility and two other involved staff are still employed and on schedule at the facility. ADM stated that the two involved staff are scheduled with other staff in ratio with them.

During visit, LPA Marrufo obtained a copy of the Medication Administration Record (MAR) which indicated that R1 was not assisted with the self-administration of M1 at 2:00 AM on 07/13/2025.

See LIC809-C page for more information. Page 1 of 2.