Facility Evaluation Report

On 5/29/2025 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced annual visit. LPA contacted Licensee, Mary Ellen Gurrola who stated staff could begin annual with Direct Support Professional (DSP), Christina. Licensee arrived some time later. LPA met with DSP, Christina Duran-Reyes, introduced self, explained reason for visit and were permitted entry into the facility. 1 resident present during visit.

LPA toured the facility. Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced on 4/11/25. Last fire drill on conducted in 5/6/25. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Refrigerator shelves missing in need of replacement. Vent exchange cover observed loose and in need of repair in hallway. Fan in bedroom #1 observed drooping and in need of replacement. Window frost in bedroom #4 observed peeling and in need of replacement. Doorway in hallway to bedrooms in need of new kick plate. Vent fan in bathroom #1 in need of trim. Water temperature in bathrooms measured over 120 degrees F. Deficiencies cited per Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D's. If not corrected the violations will have a direct and immediate risk to the health, safety and or personal rights of residents in care.