Facility Evaluation Report

Unannounced Plan of Correction visit made out to this facility on 04/02/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Sherill Lindo. A brief interview was conducted with the facility staff person at this time.

This LPA requested that she go ahead and contact the facility designated Administrator to inform them that CCL was present at this time. It was learned that the facility designated Administrator and the Licensee were unable to be present at this time. All forms were signed and given to the present caregiver at this time.

The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 03/25/2026. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 03/25/2026:

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.