Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/06/2025. At 9:10 a.m., the LPA met with staff and explained the reason for the visit. Administrators Victor and Celesty Hernandez arrived shortly thereafter and were explained the reason for the visit.

RECORD REVIEW : Starting at 09:20 a.m. the LPA conducted a file review. The LPA observed documentation of Infection Control Plan, Emergency Disaster plan and last disaster drill conducted on 06/01/2025. The LPA conducted file review for five (5) out of six (6) resident files and the following was observed: Three (3) out of five (5) residents had medical assessments that were over a year old, no other documentation of a routine annual visit was on file and all five (5) residents did not have Consent for Emergency Medical Treatment forms (LIC627C) on file, otherwise everything else was complete and current. The LPA conducted file review for five (5) out of six (6) staff files and the following was observed: S1 was missing 4 hours of postural support, restricted health conditions and hospice training, S2 and S3 were missing all of their annual training. Otherwise everything else was complete and current.

MEDICATION REVIEW : Starting at 11:30 a.m. the LPA conducted a medication review for two (2) residents.

Medications are stored in a locked office inaccessible to residents in care. Medications observed were labeled, stored, and properly documented at the at the time of the visit. The LPA observed a night-time Gabapentin pill for Resident #1 (R1) was missing based on the start date and quantity. Upon observation, Administrator Celesty stated they had already administered today by accident, which is not in accordance to the instructions on the medication label, indicating it as a bedtime medication. Report will continue on LIC809-C, 2nd page.