Facility Evaluation Report

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/30/2025. At 8:50 a.m., the LPA met with the Administrator, Stephen Romero explained the reason for the visit.

RECORD REVIEW: Between 9:05 a.m. and 10:44 a.m., the LPA conducted a file review for six (6) consumers and for six (6) staff and observed the following: Staff have current first aid and training completed. Consumer records were reviewed for but not limited to current Individual Programming Plan (IPP), Individual Service Plan (ISP), medical assessments, admissions agreement, and consent forms. All records were in order. The last fire drill took place on 06/07/2025. The LPA observed documentation of the Infection Control Plan and Emergency and Disaster Plan. Administrator certificate is valid until 06/11/2026.

MEDICATIONS: Medications are centrally stored and locked. The facility is using a MAR and maintains a centrally stored form, which was complete. Starting at 10:45 a.m., the LPA conducted a review of medication and medication documentation with the Program Manager for three (3) consumers and observed that medications were properly documented and assisted as prescribed.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.