Non-compliance follow-up·October 22, 2025

At approximately 12:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced, to conduct a quarterly Legal/Non-Compliance visit and met with Administrator, Madonna Grace Martinez. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. At approximately 1:30 PM, LPA reviewed five (5) of five (5) resident files. LPA observed five (5) of (5) residents' files missing two (2) or more of the required documents. Administrator agrees to complete these documents and submit them to the Department by EOB 10/31/2025 in order to bring the facility into compliance. At approximately 4:00 PM, LPA reviewed previously uncleared POCs issued since the initial legal non-compliance office meeting held on 06/26/2024 with Administrator who agrees to clear by EOB 10/31/2025 in order to bring the facility into compliance with regulations. Technical Support Provider (TSP) assistance was offered to Administrator during the office meeting on 08/11/2025 where Administrator agreed to engage services. However, Administrator never responded to communications from TSP and the referral was closed. LPA discussed this option with Administrator again during today's facility visit and Administrator agreed to engage services. No citations issued during today's visit. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.