Correction check·August 19, 2025

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections visit for deficiencies issued on August 5, 2025 during a plan of correction visit. LPA was greeted and granted entry by staff. LPA discussed the purpose of the inspection with staff Keatlen Ballanes. LPA toured the facility to check the deficiencies had been corrected with staff. LPA along with staff entered four rooms randomly. LPA observed four out of four rooms with a signal system installed. LPA measured temperature of bathroom sink next to room 8 in the Winter Cottage Building. Temperature in the bathroom measured at 110.8 degrees F. Based on LPA's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due dates of August 6, 2025 and August 12, 2025, thus clearing the Type A deficiency CCR 87303(e)(2) and the Type B deficiency CCR 87303(i). An exit interview was conducted and a copy of this report was provided to the facility representative.