Routine inspection·March 11, 2026

On March 11, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Georgianna Mendez was present and assisted on today's visit. LPA observed that Georgianna Mendez has a valid Administrator certificate which expires on December 12, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for two hundred and twenty five residents, all of which can be non-ambulatory, twenty can be bedridden, and has a hospice waiver for thirty. The facility is a two building which consist of assisted living and memory care. Their are resident apartments in both areas, which have bathrooms located in suite. The facility also consist of common areas such as dining rooms in both the assisted living and memory care, activity areas, a commercial kitchen, staff offices, a salon, laundry rooms, a medication room, and a physical fitness center. LPA conducted a tour of the interior portions of the facility. On today's visit, there are ninety six residents in care. LPA observed residents eating lunch in the dining room. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected ten resident bedrooms located throughout the facility and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident bedrooms and they tested operational. LPA inspected the resident bathrooms in the apartments inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 105.6 and 118.5 degrees Fahrenheit. LPA inspected the facility kitchen area and observed it be clean. LPA observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. CONTINUED ON 809-C During a tour of the kitchen, LPA observed one staff preparing food without a hairnet. The staff advised LPA that they did not have any hairnets and that they had to be ordered. LPA observed the facility has a three day emergency food and water supply on hand. LPA observed multiple fire extinguishers to be mounted in the wall across the facility. All fire extinguishers were observed to be charged and serviced as of August 12, 2025. LPA observed that the facility had their most recent Fire Inspection conducted on August 22, 2025. LPA observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPA observed the facility conducted their last emergency disaster drill on December 11, 2025. LPA observed the centrally stored medication to be kept in locked medicine carts located throughout the facility. LPA observed first aid kits to be stored in the medication room and they had all the required components. LPA observed all the facility's chemicals and toxins to be stored in a locked storage rooms. LPAnconducted a tour of the exterior portions of the facility. LPA observed the facility has outdoor areas for both assisted living and memory care. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use. LPA tested the delayed egress doors located on the exterior portions. One delayed egress door in the memory care portion was non-operational at time of visit. LPA reviewed ten resident files. LPA observed the Reappraisals on file for Resident #2 (R2), Resident #6 (R6), and Resident #7 (R7) were outdated and need to be updated. LPA reviewed residents' medication and medication administration records. LPA observed the facility did not have one medication for Resident #11 (R11) present at the facility, despite R11 having an active order for the medication. LPA observed the facility did not have three medications for Resident #12 (R12) present at the facility, despite R12 having active orders. LPA reviewed ten staff files. LPA observed that Staff #1 (S1) did not have any annual training on file for the year of 2025. LPA observed that Staff #11 (S11), Staff #12 (S12), Staff #13 (S13). Staff #14 (S14), Staff #15 (S15), and Staff #16 (S16), were not criminal background cleared or associated to the facility. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. Civil penalties will also be assessed in the amount of $3,000.00 for criminal background clearance. An exit interview was conducted with Executive Director Georgianna Mendez. A copy of the report and Appeal Rights were provided.