Facility Evaluation Report

At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Assistant Administrator Theresa Burdick and Administrator Nickie Perez and informed them of the reason for the visit.

Record Review: A review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, Disaster prevention and last disaster drill (conducted on 11/12/2025). The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of twenty-seven (27) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All resident records were in order. The LPA reviewed five (5) of twenty-two (22) staff files. Personnel records and Administrator’s file were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records were complete and current.

Medications: A medication review was conducted for three out of five residents and the following was observed. The medications were stored in a medication room and med carts which are locked and inaccessible to the residents. Medications are properly documented on the Centrally Stored Medication and Destruction Record (CSMDR).

Interviews: The LPA conducted three (3) resident and three (3) staff interviews. No concerns were voiced. Report will continue on LIC809-C, 2nd page.