Follow-up·April 17, 2025

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Oana Abrudan arrived at 8:45 am. Per review of approved facility sketch dated 02/01/2016 there was no indication there was a designated "Rec Room" and it was listed as Resident Room #1 at 11 X11 for measurements. Based on the current submitted facility sketch dated 10/28/2024 Resident Room #1 is 12 X11 with an interior wall connected to the "Rec Room". Per previous floor plan neither Rec Room or Resident Room 1 had a window or door labeled. Per review of facility sketches Resident Room #3 was previously designated as Caregiver Room, facility Administrator Oana will confirm if room was designated as non- ambulatory at initial fire clearance approval. Based on observations made during today's visit deficiencies are being cited. An exit was conducted and a copy of this report and appeals rights were provided to Administrator.