Routine inspection (multi-day)·August 28, 2025

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit continuing the inspection that began on 11/18/2024. The LPA met with Executive Director (ED) Christian Castillo. Entrance interview conducted. Medication Audit: At 12:00 p.m. the LPA conducted Medications audit for two (2) residents. The medications are locked in medication carts. Medications are labeled and checked for expiration dates. Medications were observed to not be properly documented on the centrally stored medications and destruction record (CSMDR). During Resident 1's (R1's) audit the LPA observed three medications were not documented on the CSMDR, all medications were missing start dates on the CSMDR, and one medication did not have the date filled on the CSMDR. However, all the information was on their online system. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.