Routine inspection (multi-day)·October 1, 2025

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an additional continuation of the comprehensive required annual inspection that commenced on September 15, 2025. LPA identified herself to Med Tech Allan Bartalome (S1) and was granted entry into the facility. Staff Yasar (S2) later arrived at the facility and joined the inspection. A review of staff records revealed there was no documentation on staff training, and an interview with S2, S1, and S3 confirmed staff had not received the required training prior to their starting date. The records review also revealed two (2) of the staff members were missing additional required records on file. An interview with S2 and a facility records review also showed staff had never participated in a disaster drill, could not provide an infection control plan, nor provide current liability insurance. LPA, accompanied by S1, inspected the facility kitchen. LPA observed the facility kitchen to be unsanitary, including dead pests in the kitchen cabinets/drawers, and in need of deep cleaning. The inspection did reveal the facility had an adequate amount of food, that included a 2-day supply of perishable and 7-day supply of non-perishable food, and sharps (e.g., knives) were observed stored in a locked cabinet. LPA also observed all essential dishware and utensils needed for cooking and eating. In addition, the facility was equipped with smoke and carbon monoxide detectors, and fire extinguishers, that were all operable and/or up to date. A review of the resident Medication Administration Records (MARs) revealed Resident1 (R1) ran out of their daily heart medication on approximately July 15, 2025, and had not received a refill since, in addition, Resident 2 (R2), was going on the second day of missing their medication also due to running out and not receiving a refill. LPA observed the medications were stored in a locked medication cart, and medications that required refrigeration, were locked in a mini refrigerator. LPA observed resident rooms and bathrooms to be equipped with the required furnishings and safety equipment. Water at taps used by residents measured in compliance with regulation. The facility has a large common area and outdoor shaded area for residents’ activities and visitation. Required licensing postings were in visible areas of the facility. No pools or bodies of water were on the premises. Per S2 there are no firearms or ammunition kept at the facility. LPA concluded the required annual inspection during today’s visit, however, will be returning to issue citations for the above-described violations. An exit interview was conducted with Staff Yasar (S2) to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit.