Correction check·April 29, 2026

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction clearance. LPA Lopez identified herself and was allowed entry by Administrator Norma Tomas. LPA met with Administrator Tomas and discussed the purpose of the visit. On 03/16/26, the facility was issued four (4) deficiencies [Plan of Corrections (POC)] for not having an updated Administrator’s Certificate, medications not being in their original containers, a quarterly fire drill, and a medication list for residents with centrally stored medications. During today’s visit, LPA was provided with information regarding their Administrator’s Certificate, which was in progress. The facility had agreed they would contact the Technical Support Program (TSP) for assistance with recertification, which was completed. This POC is deemed cleared during this visit. The facility agreed to follow up with LPA once they have obtained their certificate. The facility was issued a citation for obtaining medications in pill boxes, and according to their POC, they decided to remove the pill boxes and maintain their medications in their original containers. During the visit with TSP, they assisted with ensuring that the facility was within the scope of Title 22 regulations, and they were advised only to pour daily medications. LPA observed that the facility was in compliance and observed that only the medications for that day were poured. Based on the Department's instructions and LPA's observations, the facility is within the scope of the regulations. This citation is deemed cleared during today’s visit. (Continuation on LIC809-C) (Continuation of LIC809) The facility was issued a citation for not conducting their quarterly fire drill. According to their POC, they were to conduct a fire drill. During today’s visit, LPA observed that the facility had completed their quarterly fire drill in March 2026. They are aware that their next fire drill will be conducted in June 2026. Based on LPA's review of the record, this citation is deemed cleared during today’s inspection. The facility was issued a citation for not having updated medication lists for resident #1 (R1 – see confidential names list), resident #2 (R2 – see confidential names list), and resident #3 (R3 – see confidential names list). An updated medication list was provided for R1, but the facility was unable to provide an updated medication list for R2 or R3. This POC is not deemed cleared during today’s visit, and a failure to correct will be issued. No additional deficiencies were observed, but a civil penalty (CP - LIC421FC) for failure to correct was issued during today’s visit. An exit interview was conducted, CP was issued, and a copy of this report, along with Licensee Rights (LIC 9058 03/22), were provided to Administrator Norma Tomas at the conclusion of the visit. The signature below confirms receipt of these documents.