Most inspections found no deficiencies, with the facility consistently maintaining clean, safe, and well-managed conditions. The most recent report from October 28, 2025, was perfect with no deficiencies noted. Earlier reports included one deficiency in November 2021 related to an unsecured medication cabinet, which posed a safety risk, but no enforcement actions or fines were listed. Several complaint investigations were unsubstantiated or unfounded, including allegations about medication refills, medical record accuracy, and staff neglect. Overall, the facility’s compliance has improved since the 2021 finding, and recent inspections show no current issues.
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with regulations, including physical plant conditions, medication storage, food service, care and supervision, records, disaster preparedness, and infection control. No deficiencies were noted during the visit.
Report Facts
Capacity: 20Census: 16
Employees Mentioned
Name
Title
Context
Emely C. Rodriguez
Licensee / Administrator
Met with Licensing Program Analyst during the inspection and named in the report
An unannounced case management visit was conducted by Licensing Program Analysts to assess the facility's compliance and resident care conditions.
Findings
The facility was found to have no imminent health or safety concerns. Staffing levels were adequate, food and medication supplies met requirements, and the facility was clean and well-maintained.
Report Facts
Staff per shift: 3Food supply duration: 2Food supply duration: 7
Employees Mentioned
Name
Title
Context
Emely C. Rodriguez
Administrator
Met with Licensing Program Analysts during the visit
The inspection was an unannounced required annual inspection conducted to assess compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and in compliance with department requirements including infection control, physical plant safety, food service, staff certifications, medication security, and disaster preparedness. No deficiencies were cited during the visit.
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not refill a resident's medication prescription in a timely manner and that staff did not keep an accurate medical log for residents.
Findings
The investigation found the allegation regarding the medication refill to be unfounded as medication was available and administered appropriately. The allegation about inaccurate medical logs was deemed unsubstantiated as no discrepancies were found in medication records or administration documentation.
Complaint Details
The complaint involved two allegations: 1) staff did not refill a resident's medication prescription timely, and 2) staff did not keep an accurate medical log for residents. The first allegation was found to be unfounded, meaning it was false or without reasonable basis. The second allegation was unsubstantiated, meaning there was insufficient evidence to prove the violation occurred.
Report Facts
Capacity: 20Census: 17
Employees Mentioned
Name
Title
Context
Stephanie Martinez
Licensing Program Analyst
Conducted the complaint investigation visit
Emely Rodriguez
Administrator
Facility administrator met during the investigation
The visit was an unannounced annual inspection conducted by Licensing Program Analyst Chinwe Nwogene to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be in good repair, operating within approved capacity, and maintaining safe and sanitary conditions. No deficiencies were cited during the inspection.
The visit was conducted to address a potential violation reported during the investigation of complaint #18-AS-20230314155846 involving a resident sustaining injuries after being pushed by a staff member.
Findings
The Licensing Program Analyst conducted staff and resident interviews, reviewed records, and video surveillance related to the incident. The video showed a resident arguing with an unidentifiable individual and the staff member stumbling and falling, but did not clearly capture the alleged pushing incident. Further follow-up will occur if additional information indicates a violation.
Complaint Details
The complaint involved a resident (R1) who reported being pushed by an unknown staff member (S1), resulting in a head injury and hospital transport. The incident was reported on March 14, 2023, and emergency services were called due to bleeding from a fall.
Report Facts
Complaint number: Complaint #18-AS-20230314155846 referenced in the investigation
Employees Mentioned
Name
Title
Context
Stephanie Torres
Licensing Program Analyst
Conducted the unannounced visit and investigation
Emely C. Rodriguez
Administrator
Facility administrator named in the report
Luz Rodriguez
Care Consultant
Met with the Licensing Program Analyst during the visit
The visit was an unannounced complaint investigation initiated due to an allegation of staff neglecting a resident, received on 06/08/2020.
Findings
The investigation found that a resident called for help and staff responded promptly, but the resident was found on the floor and later had difficulty breathing. The allegation was deemed unsubstantiated due to insufficient evidence to prove the violation occurred. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged staff neglected a resident. The investigation included review of records and staff interviews. The resident had passed away and could not be interviewed. The allegation was found unsubstantiated.
Report Facts
Capacity: 20Census: 12Investigation duration: 101Time resident was on ground before 911 call: 5
Employees Mentioned
Name
Title
Context
Ryan Gardner
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Emely Rodriguez
Administrator
Facility administrator met during the investigation and exit interview
The inspection was an unannounced required annual visit with emphasis on infection control.
Findings
The Licensing Program Analyst observed sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
Employees Mentioned
Name
Title
Context
Emely C. Rodriguez
Administrator
Met with Licensing Program Analyst during inspection and discussed infection control practices.
Venus Mixson
Licensing Program Analyst
Conducted the inspection and made observations regarding infection control.
Jazmond D Harris
Licensing Program Manager
Named in the report as Licensing Program Manager.
Erlinda Covington
Facility Manager
Greeted and granted entry to Licensing Program Analyst.
The inspection was an unannounced annual inspection limited to infection control conducted to evaluate the facility's compliance with COVID-19 best practices and other regulatory requirements.
Findings
The facility was found to be generally compliant with infection control practices including COVID-19 mitigation, staff training, and resident hygiene supplies. However, there was insufficient PPE supply readily available to staff, staff had not been fit tested for N95 masks, and one medication cabinet was found unlocked, posing a safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Unsecured medication cabinet in the medication room, which poses an immediate health and safety risk to persons in care.
Type A
Report Facts
PPE supply duration: 30Facility capacity: 20Resident census: 15
Employees Mentioned
Name
Title
Context
Emely C. Rodriguez
Administrator
Met during inspection and involved in infection control discussion and medication cabinet locking
Crystal Colvin
Licensing Program Analyst
Conducted inspection and issued deficiency and technical assistance notes
Joel Esquivel
Licensing Program Manager
Supervisor overseeing the inspection
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