Weaver's Primrose Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Cesar Baldovino. Administrator Juliann Cruz arrived during the visit. The facility has a licensed capacity of 6 non-ambulatory residents, 1 may be bedridden and has a hospice waiver for 6 residents. During today’s visit, the facility had a census of 6 residents, 1 of which was bedridden. The Administrator for the facility is Juliann Cruz and their certificate was valid and current. During today’s visit, LPA inspected each room of the facility, including resident and staff rooms, private and common bathrooms, kitchen, garage, common areas, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. LPA observed PM and bedtime medication doses for 6 residents stored in plastic containers in a locked cabinet in the kitchen. According to Juliann Cruz, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records. The following deficiency was cited for medication storage and noted on the attached LIC809-D page. An exit interview was conducted with Administrator Juliann Cruz, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Cesar Baldovino. Administrator Tonya Weaver arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 6 residents, 5 non-ambulatory, and 1 bedridden. 2 residents were on hospice. The Administrator for the facility is Lisa Anderson-Hines and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 113.5 degrees Fahrenheit in a private resident bathroom and 106.9 and 107.4 degrees Fahrenheit in common bathrooms. The facility’s internal temperature was measured at 71 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Tonya Weaver, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and appraisal assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Tonya Weaver via telephone and staff Gladys Baldovino, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jan 3, 2025

Allegation investigated: Staff handled resident in a rough manner resulting in an injury Staff makes inappropriate comments to resident Staff did not get consent from authorized representative to feed resident solid foods Staff does not allow residents to speak with each other

Licensing Program Analyst (LPA) Daniel Pena conducted a complaint investigation visit at Weaver Primrose Villa. After identifying himself, LPA was permitted into the facility. LPA met with and discussed the elements of the complaint with Rene Verceles, Caregiver. The purpose of the visit was to initiate a complaint investigation and deliver findings. The Department's investigation included facility tour, interviews with outside sources, staff, and pertinent residents as well as review of pertinent facility records. On 02/13/24, it was alleged staff handled Resident 1 (R1) in a rough manner, causing injury; made inappropriate comments to residents; did not obtain consent from R1’s authorized representative to feed the resident solid food and did not allow residents to speak with other residents. LPA conducted a review of R1's records as part of this complaint investigation. R1’s records contained no Unsubstantiated documentation revealing a leg injury. Staff denied ever roughly handling any resident. Staff also has not witnessed any staff roughly handle any resident. Interviews with outside sources which included resident family members, did not report ever witnessing staff call residents spoiled brats or undeserving of care. Staff and outside sources consistently reported that staff treat all residents like family and with respect. R1’s records indicate that R1’s medical orders include notes that R1’s has been approved to eat solid foods since 2023. When interviewed, staff said they strictly follow resident’s written food orders but not verbal requests. Staff understands the liability in not following a resident’s medical provider’s orders. Interviews indicate that no staff has ever themselves or witnessed another staff not allow residents to speak with each other. Several interviews noted that a particular resident’s family member was asked not to speak to residents that have swallowing difficulty. Staff has also asked this same family member not to discuss sensitive private matters with residents. The Department has investigated the allegations that Weaver’s Primrose Villa staff handled R1 in a rough manner, causing injury; made inappropriate comments to residents, did not obtain consent from R1’s authorized representative to feed R1 solid food, and did not allow residents to speak with other residents. Based upon interviews and records, there is insufficient evidence to uphold any of the allegations, therefore the Preponderance of Evidence standard was not met. As such, the allegations are Unsubstantiated. An exit interview was conducted with Caregiver, Verceles, and a copy of this report was provided to Mr. Verceles, whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 08-AS-20240213152831

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Rosemarie Verceles. LPA spoke with Administrator Babette Gardner via phone and Licensee Tonya Weaver arrived during LPA's visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 4 non-ambulatory residents. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Babette Gardner and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to the Licensee Tonya Weaver, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 109.9 degrees Fahrenheit in a common bathroom and 106.5 degrees Fahrenheit in a private resident bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page... LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. No deficiencies were observed or cited on today’s date. An exit interview was conducted with Licensee Tonya Weaver, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Jan 12, 2024