Villa Marin Ambulatory Care Unit

FACILITY EVALUATION REPORT

The facility underwent a Case Management - Annual Continuation visit on 07/15/2025. The general physical environment, safety measures, and staffing were found to be adequate. However, a deficiency was cited regarding the maintenance and documentation of centrally stored medication records.

The facility underwent a Required 1 Year Visit and the Licensing Program Analyst was unable to complete the full Annual Inspection. The report notes that no deficiencies were cited during the visit, and the facility was found to have an approved fire clearance and that staff files were well-organized and current. A follow-up Annual Continuation Visit is required to complete the review of staff training, resident files, and resident medication.

This report details a complaint investigation conducted regarding resident rights to meetings and recording. The investigation reviewed records and conducted interviews, concluding that both allegations were unfounded based on the circumstances described. No deficiencies were cited during this visit.

This report details a complaint investigation conducted regarding resident rights to meetings and recording. The investigation reviewed records and conducted interviews, concluding that both allegations were unfounded based on the circumstances described. No deficiencies were cited during this visit.

The inspection was a Case Management - Annual Continuation visit conducted on December 18, 2024. Two deficiencies were cited: one regarding missing negative TB test results in resident files, and another concerning inconsistent documentation of medication expiration and fill dates. Both deficiencies are classified as Type B, requiring corrective action.

The facility underwent a Required 1 Year Visit on August 22, 2024. The inspection noted that the facility was clean, had appropriate supplies, and that staff were background cleared. However, the LPA was unable to complete the Annual Inspection and scheduled a follow-up visit.

This report details a Complaint Investigation conducted on 04/03/2024 regarding an allegation that the licensee failed to issue a refund to a resident's authorized representative. The investigation found the allegation to be Unfounded after reviewing facility documents and conducting interviews.