Follow-up·February 24, 2025

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a Case Management visit with the purpose of verifying a pending increase in capacity and updating bedridden for the facility. Upon arrival, the LPA was greeted by the Administrator, Monica Vigil and the reason for the visit was explained. Entrance interview conducted. A capacity change and bedridden update was requested for the facility to increase capacity from 4 residents to 6 and updating bedroom #4 to be bedridden. The fire clearance (STD850) was approved on 02/20/2025 for capacity of 5 non-ambulatory residents in bedrooms #1 - #5 and 1 bedridden resident in bedroom #4 only. During today’s visit, the LPA, along with the Administrator, toured the facility. The LPA observed that Bedroom #3, which was previously a staff room, is now set up as a shared resident bedroom. For the NOC shift, awake night staff will be present. Additionally, Bedroom #4 has a direct exit to the outside. Both the main hallway leading to the resident bedrooms and Bedroom #4 were observed to be equipped with fire doors. Physical plant is consistent with the submitted facility sketch/floor plan. No physical plant or health and safety concerns were noted during today's visit. No citations issued. Exit interview conducted. A copy of today's report was provided.