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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209106
Report Date: 01/08/2026
Date Signed: 01/08/2026 06:31:10 PM

Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TLC HOME CARE 1FACILITY NUMBER:
157209106
ADMINISTRATOR/
DIRECTOR:		ARRIETA, RODRIGO A. JR.FACILITY TYPE:
740
ADDRESS:5801 COCHRAN DRIVETELEPHONE:
(661) 558-4499
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 6DATE:
01/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Teresa ReyesTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 01/08/2026, Licensing Program Analyst (LPA) J.Duarte and LPA S. Doucette, arrived unannounced to conduct an annual inspection. LPAs introduced self, stated the purpose of the visit, and were greeted by staff. LPAs were granted entry. Staff contacted Administrator Rodrigo Arrieta and he arrived shortly after.

LPAs toured the facility with Administrator Rodrigo and Staff Teresa Reyes. The facility was observed to be at 72 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed. The common areas were well lit with adequate seating for residents. The facility had a two-day supply of perishable and seven-day supply non-perishable food. Chemicals and sharps were observed locked in kitchen cabinets. Medications and the first aid kit were also observed in a locked kitchen cabinet. LPAs observed the door from the dining room into the laundry room was locked and the laundry room, leads to the staff office, which is a fire exit (Exit #3 on the sketch).

The hot water in the restrooms measured 105.5 and 109.5 degrees F. Resident bedrooms were toured and LPAs observed a second bed in R3's room being utilized to block R3's closet, to keeep R3 from accessing their closet space.

The facility conducts their own laundry and has a washer and dryer. Detergent and chemicals were observed stored in the laundry room. A second fridge was observed in the garage. LPAs observed refrigerated medication is stored in a a lock box with no lock in a fridge in the garage. The garage is also kept unlocked.

Continued in LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the door from the dining room into the laundry room was locked and the laundry room, leads to the staff office, which is a fire exit (Exit #3 on the sketch), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee removed the locked door to allow access to exit #3. A RepeatCivil Penalty was assessed and issued. POC corrected during visit.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that the start date for R1's Losartan medication was on 12/18/25. Started with 30 pills, has eight pills left. Medication Hydrochlorothiazide has the same start date of 12/18/25 and started with 30 pills; however, has nine pills left. Both medications are administered in the morning according the MARs log. Hydrochlorothiazide medication was not administered, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee will schedule medication training for staff and provide an agenda to CCL by POC due date of 01/09/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that Insulin medication was stored in a a lock box with no lock in a fridge in the garage. The garage is also kept unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee obtained a lock for the lock box to secure the insulin medication. A civil penalty was assessed and issued for repeat violation. POC corrected during this visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record revidew, the licensee did not comply with the section cited above in that facility staff did not log on the centrally stored log, R1's medication of Doxazosinmesylate,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee stated that a training will be conducted on logging centrally stored medication. Licensee will schedule training and provide proof once training is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87623(b)(B)
(b)In addtion to section 87611, Gerneral requirements for allowable health conditions, the licensee shall be responsible for the following:(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that the facility staff do not have training by skilled professional for R2's restricted health condition, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee will obtain traning for all staf for R2's restricted health condition and provide proof to CCL by POC due date of 1/15/26.
Type B
Section Cited
CCR
87464
(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that the hospice care plan for R1 indicates to record blood pressure readings and provide guidance for elavated readings on when to seek medical attention;however, Facility staff are not recording blood pressure readings for R1 and were not trained on when the reading would require medical attention, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee agrees to submit a plan on how staff will meet R1's needs and obtain training from hospice, and submit copies of training for each staff by POC due date of 1/15/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87568.1(a)(13)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(13) To have access to individual storage space for private use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that the licensee used a second bed to block R3's closet, to keeep R3 from accessing the closet space, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee removed the additional bed from R3's bedroom to allow R3 acess to their closet space.
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the fire extinguiser was last serviced on 09/17/2024,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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Licensee stated that a fire extinguisher will be serviced tomorrow and will provide proof to CCL by POC due date of 1/09/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106
VISIT DATE: 01/08/2026
NARRATIVE
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    Continued from LIC 809.

    Resident’s medications were reviewed along with the MARs. LPAs observed the start date for R1's Losartan medication was on 12/18/25. Started with 30 pills, has eight pills left. Medication Hydrochlorothiazide has the same start date of 12/18/25 and started with 30 pills; however, has nine pills left. Both medications are administered in the morning according to the MARs log. Medication Hydrochlorothiazide has one extra pill that was not administered. Facility staff did not log on the centrally stored log, R1's medication of Doxazosinmesylate.S4 stated that they ran out of R1's Doxazosin Mesylate which was supposed to be administered at 5 PM. Facility has not received medication, causing a medication error. R3 and R4 do not have hospice care plan in their files. R1 has a hospice care plan which indicates facility staff are to take R1's blood pressure; however, there is no log indicating care is being provided. Care plan states facility supposed to seek medical attention if blood pressure is high; however, facility does not have a guide to instruct staff on when to seek medical attention.

    A fire extinguisher was observed with a service date of 09/17/2024.

    The last fire drill was completed on 10/22/25, per staff records. Smoke and carbon monoxide detectors were tested and observed to be operational. Staff files were observed to be complete with criminal record statement and health screening. Resident files were observed to be complete with physician reports.

    A deficiency is being cited on, see LIC 809D. A Repeat civil penalty was assessed and issued for fire clearance. A repeat civil penalty was assessed and issued for not locking centrally stored medications.

    Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

    Residential Care Facility for the Elderly (RCFE):


    · LIC 308 Designation of Facility Responsibility
    · -as applicable: LIC 309 Administrative Organization
    · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · -as applicable: LIC 402 Surety Bond
    · LIC 500 Personnel Report
    · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
    · LIC 9020 Register of Facility Clients/Residents
    · Copy of current Liability Insurance
    · Copy of current Administrator Certificate
    · Alternate contact information including name, telephone number, & email address.

    Please submit the above forms/information to Fresno CCL by: 01/15/2025.

    An exit interview was conducted and a plan of corrections was developed with the administrator. A copy of this report and appeal rights were provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
LIC809 (FAS) - (06/04)
Page: 9 of 9
Document Has Been Signed on 01/08/2026 06:31 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 01/08/2026 at 05:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TLC HOME CARE 1
FACILITY NUMBER: 157209106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(4)
87633 Hospice Care of Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:
(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in that R3 and R4 do not have a hospice care plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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2
3
4
Licensee stated that a copy of the hospice care plans will be requested and placed residents file by POC due date of 1/15/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
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