Facility Evaluation Report

On 04/20/2023 at 11:50am, Licensing Program Analysts (LPAs) Arielle Pascua and Avellina Martinez arrived unannounced to this facility to conduct a case management visit. LPA Pascua knocked on the facility door twice and no one answered the facility door. At 11:57am, LPA Pascua called Facility Designated Administrator, Julian Hawes and was unable to reach the FDA at this time. LPA was unable to leave a message due to the voicemail box being full.

On 04/21/2023 at 8:00am, Regional Manager (RM) Stephenie Doub and Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a complaint visit. RM and LPA were greeted by staff member, Alma Moyamoy and explained the purpose of the visit. RM and LPA asked SM Moyamoy to call the Facility Designated Administrator to inform them that CCL was present. Upon waiting for the Facility Designated Administrator (FDA), at 8:10am, LPA and RM observed an unlocked padlock on the black medication cabinet located in the office. In addition, LPA and RM observed a resident's bubble pack located in a Minnie Mouse bag on the top of the black office desk. At 8:20am, RM and LPA met with FDA Julilan Hawes. There were two other staff members present, Iboni James and Jada Hull.

Current Census was 4. 1 out of 4 residents were out at their respective day program.

On 04/05/2023 at 10:00am, LPA Pascua and Licensing Program Manager (LPM) Emerita Curiel arrived unannounced at the facility to conduct a complaint visit. At 10:02am, LPA Pascua and LPM Curiel were greeted at the door by Staff 1 (S1) and asked that they call the Facility Designated Administrator to inform that that CCL was present. At 10:05am, S1 closed the door and did not allow LPA Pascua or LPM Curiel into the facility and stated that they would call FDA. At 10:10am, LPA Pascua knocked on the door to see if S1 notified the FDA that CCL was here. LPA Pascua was unable to get a staff member to open the door. At 10:11am, LPA Pascua called FDA and was not able to reach the FDA at this time. At 10:12am, LPA Pascua received a call from the FDA and informed them that CCL was present. It was stated that they were not informed by S1 that CCL was present and would be at the facility in 2 minutes. At 10:15am, LPA Pascua and LPM Curiel met with FDA Hawes and were able to obtain entrance to the facility.