Facility Evaluation Report

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced visit at the facility in conjunction with a complaint investigation that occurred today. LPAs met with Executive Director (ED) Monica Reyes and explained the reason for today’s visit. Entrance interview conducted.

During today’s facility tour, conducted with the ED and began at 11:19AM, LPAs observed the exhaust fan in the facility’s commercial kitchen to be non-operational. Staff interviewed stated that the exhaust fan has been broken for 2 (two) weeks. Kitchen staff have continued to use the burners and ovens located underneath the exhaust fan/hood, even though the hood is clearly labeled “CAUTION Exhaust fan must be turned on before lighting cooking appliances.” While in the kitchen, LPAs observed a kitchen staff with a burner lit and pot on the stovetop cooking. LPA Dulek spoke with Fire Inspector over the phone, who indicated the exhaust fan is an integral part of the facility’s fire safety system and must be functional at all times. Additional concerns in the kitchen related to maintenance are as follows: walk in freezer is broken and is being utilized as a refrigerator, kitchen vent is very dirty and does not allow air to flow into the kitchen area, and dishwasher is broken.

During medication review, which began at 12:53PM, LPAs observed Resident #1 (R1) was recently hospitalized twice related to their diabetes diagnosis. Prior to R1’s hospitalization, R1 was prescribed oral medication for diabetes control and had an order to check blood sugar twice daily before meals. Following the first hospitalization, R1’s medications were changed and R1 required regular daily insulin injections as well as blood sugar checks twice daily. After R1’s second hospitalization, R1’s medications were changed again, and as of 07/19/2025, R1 was prescribed insulin on a sliding scale. R1 has a diagnosis of dementia