Facility Evaluation Report

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs met with Executive Director (ED), Monica Reyes and explained the reason for the visit. The LPAs focused today’s visit on physical plant, resident files and incident reporting in compliance with Title 22 Regulations.

During today's visit, the LPAs, along with ED, conducted a physical plant tour beginning at 11:23AM and LPA Dulek conducted file review at 01:26PM. The following was noted:

Upon arrival to the facility, LPAs observed the delayed egress gate on the north side of the memory care was observed to be tied shut with a plastic bag, preventing the gate from opening. During facility tour, at 11:50AM, the other delayed egress exit gate was observed to be locked with a key. Maintenance staff confirmed that the gate had been locked since Sunday 08/10/2025.

During file review, LPA Dulek reviewed files for 7 (seven) residents for documents including but not limited to: physician's reports, needs and service appraisals, and admission agreements. 2 (two) of 7 (seven) residents' files reviewed (Resident #1 - R1 and Resident #2 - R2) had needs and service appraisals that were more than 1 year old. Resident #3 (R3) has a needs and service appraisal dated 01/31/2025. However, based on review of incident reports and interview with staff, R3 has had a change in condition as evidenced by increased aggression and sexual behaviors, but staff did not complete a new needs and service appraisal for R3.