Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct Case Management/Collateral visit and met with Charito Santos, Administrative Assistant. LPA conducted interviews with resident (R11) regarding complaint unrelated to this facility. The purpose of this case management inspection is to follow up on self-certifications received to clear deficiencies cited during annual inspection on 7/7/2026:

- 87465(c)(2) - medications were not given as prescribed by residents' physician: LPA learned that on 7/27/26 a pharmacist consultant from pharmacy vendor came to review medications with staff. According to administrative assistant, the facility is training another staff to help with medication management.

- 1569.618(c)(3 ) - Staff did not have current CPR certificates. During today's visit, LPA observed that three staff (S2, S3 & S4) have current CPR/1st aid certificates on file.

- 1569.625(b)(2) - Staff did not have additional 20 hours annually of required training. LPA was provided with proof of additional 20 hours of training completed by two staff (S3 & S4).

- 87463 (a) - 10 out of 30 residents care plans needed to be updated. LPA reviewed records of care plans were updated for ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10).

- 87507(c) - All residents need to sign the addendum regarding surveillance cameras. All residents signed and dated addendum acknowledging the presence of surveillance cameras.

No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and copy of this report was given.