Routine inspection (multi-day)·September 16, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent Required-1 year visit. LPA was met by Raquel Salen and Lucia Ramos, Care Staff and explained the purpose of the visit. Shortly after, Administrator Elna Villaflor arrived and assisted LPA. LPA continued to utilize the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate is valid and expires on 06/05/2026. Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full and half bed rails were reviewed in the resident files. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Incidental Medical Services: Medications reviewed for all (5) residents. Residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (4) residents under hospice care receive Home Health care in the facility. Residents medication are centrally stored in a locked cabinet next to the kitchen area. Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. During medication review, LPA observed the staff failed to sign the Medication Administration Record (MAR) for the a.m. medications administered on the correct date (09/16/2025)for all (5) residents. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis. Last fire drill was conducted on 09/05/2025. Residents with SHN : Four (4) residents receive hospice care. Appraisals were observed in resident files. Information regarding Dementia is part of the training for direct care staff. Deficiency cited, Technical Assistance and Technical Violation issued. Exit interview and a copy of this report along with the appeal rights were provided to the Administrator, Elna Villaflor.