Follow-up on corrections·July 3, 2025

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management Visit. LPA met with Administrator, Armond Hagan, who was informed of the purpose of the visit. LPA later met with Staff, Aidan Hagan. LPA made (3) attempts to contact the licensee during the time of the visit, however no response was received. LPA conducted a walk through, interviews, and records review. LPA conducted a health and safety check on the resident's at the time of the visit. LPA observed (2) residents in care and (2) cleared staff present at the time of the visit. No immediate health or safety issues were observed. A file review revealed annual conducted on 02/22/2024, and continued on 02/26/2024 had uncleared deficiencies that were verified at the time of the visit. Citation for uncleared adults observed 02/22/2024 was issued. During today's visit LPA did not observed any uncleared adults in the facility, therefore the deficiency was cleared. Deficiency was issued for medications that did not have a stop of discontinuation order on file for the resident. LPA reviewed the medications during the time of the visit and found all medications accounted for with doctor's orders and on medications lists. Therefore, this deficiency was also cleared at the time of the visit. Deficiency was cited for medications being stored in weekly pill boxes and outside their originally received containers. During today's visit LPA observed the resident medications in their originally received containers. Therefore the deficiency was cleared. Deficiency was issued for the prior administrator and licensee Jacqueline White not having their CPR and first aid certification available for review. LPA reviewed the file for the licensee and found no CPR certificate on file. Therefore a deficiency was issued. Deficiency was issued for LIC503 Health Screening and TB test for the previous administrator and licensee, Jacqueline White. LPA requested the file for the licensee and found no LIC503 documented for the licensee. Therefore a deficiency was issued. Deficiency was issued for the facility not having a copy of their currently liability insurance. During the visit LPA requested a copy of the facility's liability insurance and found no liability available for review at the time of the visit. Therefore a deficiency was issued. Deficiency was cited for the facility not having an emergency and disaster plan on file. During the visit the LPA reviewed the facility's emergency and disaster plan which revealed the plan did not meet the Title 22 requirements. The licensee must update the plan. New deficiency was cited for the licensee to update the emergency plan. Deficiency was cited for the facility not conducted a quarterly fire drill. during the visit LPA reviewed the last fire drill and found no documented fire drill at the time of the visit. Therefore a deficiency was issued. An exit interview was conducted with staff, Aidan Hagan where this report and deficiency pages, and appeal rights were reviewed and provided. *LPA was off site from 12:05pm to 1:49pm in order to prepare today's report.