Follow-up·October 10, 2025

On 10/10/2025 at 2:20 PM Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a case management visit for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA explained the purpose of today's visit and met with facility staff Jeanne. The Administrator Christine Torres was not present during today's visit. During today's visit LPA spoke over the phone with the facility administrator Christine, and explained the purpose of the visit. Administrator agreed to remove S1 from all shifts, and disassociate S1 in Guardian. LPA Hughes reviewed the facilities Medication Administrator Record (MAR) and did not observe Facility staff (S1) initials on the record for October 2025. LPA reviewed 6 out of 6 facility staff personnel records present in the facility, LPA did not observe a personnel record for S1. LPA reviewed 5 out of 5 facility staff time sheets and did not review a time sheet available for facility staff S1. LPA was not able to review the facilities LIC 500 Personnel Report as the form was not present in the facility. The administrator stated the form was being updated and that they would provide CCLD with an updated copy via email. LPA handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Jeanne and explained that staff needed to leave the facility immediately if present in the facility, and disassociated in Guardian. No citations issued during todays visit copy of the report printed and provided.