Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20251107111518). LPA arrived at 9:40 A.M. and met with facility staff, Mis “Nana” Sunariyati, who contacted via telephone facility administrator. At 10:15 A.M. Facility Designee Karthiga (Karthi) Vijayakumar and Administrator, Shila Pandey arrived at the facility.

The purpose of the report is to issue citations for deficiencies observed during the initial complaint investigation. Entrance interview conducted.

During today’s visit, the LPA conducted a brief plant tour at 10:20 A.M. to ensure there are no health and safety concerns, conducted interviews with the Administrator and facility designee, two (2) staff members, and three (3) residents between 10:00 A.M. and 1:30 P.M., conducted a resident file review, and obtained copies of relevant documents.

During the course of the investigation, LPA requested Resident’s #1 (R1’s) file. LPA observed that R1 was admitted in January 2024 and that the facility completed an appraisal/needs and service plan in August 2024. The need and services plan for 2025 was observed to be a duplicate of the 2024 document, with the only difference being that the last page was dated 8/11/2025. LPA further observed that the facility indicted progress notes were used as a method of evaluating the resident’s progress, however, when the LPA requested these notes, the administrator stated that neither management nor staff are keeping progress notes and that the forms need to be revised and completed accurately.