Incident investigation·March 11, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:40AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 02/26/2025. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and staff. Entrance interview conducted. During today's visit, LPA interviewed five (5) staff members between 10:43AM-1:01PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 11:40AM-12:36PM, conducted a brief physical plant tour at 12:40PM, and attempted interviews with two (2) residents between 03:04PM-03:06PM. On 02/27/2025, the Department received a verbal incident report stating that on 02/26/2025, Resident #1 (R1)’s morning Lorazepam medication dose was not administered by Staff #1 (S1). The discrepancy of the missing dose was observed around 02:30PM, same day. R1’s hospice agency and responsible party were notified. R1 was monitored for changes in condition, no significant changes were noted. Health and Services Director (HSD) Tony Nunez conducted one-on-one trainings with S1 on 02/27/2025 and 03/04/2025. As of 03/06/2025, S1 no longer works at the facility. HSD stated that the facility will be auditing medications and plans to have a vendored medication training in the near future. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.