Incident investigation·August 12, 2025

On 08/12/2025 at 3:28PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 07/30/2025. LPA met with Daniela Hernandez, Caregiver, and explained the purpose of the visit. Paul Henry, Administrator, arrived at approximately 4:00PM. LPA explained the purpose of the visit. The incident reported occurred on 07/27/2025 and 07/28/2025. The report stated on 07/30/2025, R1’s daughter observed R1’s medication wasn’t administered as prescribed by R1’s physician during the evenings of 07/27/2025 and 07/28/2025. S2 stated during facility’s investigation of forgetting to administer R1’s medication. As of 07/29/2025, S2 is no longer working at the facility. Facility informed R1's physician and R1's daughter (RP) of missed medications. LPA interviewed staff and reviewed R1's physician's report ,new medication orders and MAR, during MAR review, it was revealed that R1 did not receive medications on the evenings of 07/27/2025 and 07/28/2025. ADM will send LPA the following documents via email: S2 dismissal letter and facility’s write-up pertaining to the incident. Continue on LIC809 Continued from LIC809 Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report provided to Paul Henry.