Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA arrived at 09:30 A.M. and met with caregiver, Jester Tapia. Caregiver contacted the Administrators by phone. At 10:00 A.M. Administrator, Michelle Racan arrived at the facility. Entrance interview conducted.

At 10:23 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 2/15/2026. The smoke detectors and carbon monoxide detectors are combined units; at 10:28 A.M they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. The following was noted:

Bedrooms: There are 6 (six) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All residents’ bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be inaccessible to residents in care. LPA observed that Resident #1’s (R1’s) bed was equipped with full bed rails, The administrator stated that R1 was recently discharged from hospice care and that the facility was awaiting removal of the hospital bed by the hospice agency. During today’s visit, care staff removed the full bed rails. Technical Violation (TV) was issued.