Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a continuation of the required annual visit at 1:10 P.M. LPA met with Administrator, Francine Figueroa and discussed the reason for the visit. Entrance interview conducted.

During the annual inspection that was conducted on 10/21/2025 LPA Conway conducted the full physical plant tour in which LPA observed the common areas, bedrooms, restrooms, kitchens, and surrounding grounds. Also, LPA obtained pertinent documentation.

During today’s visit, starting at 1:22 P.M. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations and LPA will conduct a medication and files review; the following was observed:

RECORDS: Resident Records w ere reviewed beginning at 1:43 P.M. seven (7) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records reviewed were complete. Personnel Records were reviewed beginning at 3:15 P.M. six (6) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, Nonviolent Crisis Intervention (CPI) Certificate and the appropriate training. Partial documentation requested was not available on site for review during today's visit.