Facility Evaluation Report

Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident inspection, on 3/27/25 at approximately 2:30 PM, and was greeted by Myrna Tugade, House Supervisor. LPA spoke with facility House Manager, Edward Gadia who arrived at approximately 3:00 PM. LPA was informed that the Licensee/Administrator is currently out of the country on vacation.

LPA is conducting a case management visit to obtain more information regarding concerns the Department has about Administrator Qualifications and Duties due to recent complaints and incident reports received as well as observations made during LPA's initial annual inspection visit dated 2/27/2025 and subsequent visit on 03/19/2025. During the 02/27/2025 visit, LPA requested facility submit change of administrator documentation to CCL as required to be reported to the Department within 30-days of any such change. The Department has not yet received this request or information from the facility. Today, House Manager states that a change of administrator request and supporting documentation was submitted to the Department via email communications with a previous LPA in 2023.

Today, LPA reviewed staff records and obtained copies of documents including a personnel roster/report. Additionally, LPA conducted interviews with two residents and two staff members present during today's visit. Based on observations made today and during the above mentioned facility visits, documents obtained, and interviews conducted, LPA needs to conduct further file review and investigation and will return to the facility at a later date to resolve this issue.

No deficiencies are being cited during today's inspection.

Exit interview conducted with House Manager, whose signature on form confirms receipt of documents.