Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:56 AM. LPA met with facility staff who contacted the facility Co-Administrator Jovilito Gagarin. The Co-Administrator arrived to the facility at approximately 11:10 AM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at 11:05 AM the LPA began record review to ensure that facility is in compliance with Title 22 Regulations. The following was observed:

RECORD REVIEW: Record review began at 11:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Four (4) resident files were reviewed. During the initial annual visit on 12/04/2025 LPA observed R1’s bed to contain full bed rails. During today’s (12/10/2025) file review LPA observed that R1 was no longer enrolled with hospice care. LPA informed Co-Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Co-Administrator expressed understanding and agreed to remove the full length bed rails from R1’s bed. Additionally, LPA observed R1’s appraisal needs and services plan to be dated 07/01/2024. LPA informed the Co-Administrator that reappraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Co-Administrator expressed understanding and agreed to complete an updated Appraisal Needs and Services Plan for R1.