Follow-up on corrections·November 6, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:49 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on two (2) self-reported incidents that occurred on 10/04/2025 and 10/12/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), conducted a file review for one (1) resident, and conducted a medication review for one (1) resident between approximately 09:52 AM and 01:50 PM. On 11/04/2025 at 6:37 PM and on 11/0 5/2025 at 1:32 PM Community Care Licensing Division (CCLD) received two (2) self-reported incident reports pertaining to Resident #1 (R1). The two incidents occurred at the facility on 10/04/2025 at 11:00 AM and on 10/12/2025 at 10:00 AM. LPA interviewed the ED and DOAL and asked why the reports were not submitted to CCLD in a timely manner. ED and DOAL explained that a combination of confusion between R1's hospice company not receiving a medication order and the DOAL being out sick from the facility during the times the incidents occurred both contributed to the incident reports being submitted outside of the required time frame. LPA informed ED and DOAL th at a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident . ED and DOAL confirmed that they are aware of the reporting requirement and agreed to submit all future reports to CCLD in a timely manner and ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL. Continued on LIC 809C. The 10/04/2025 self-reported incident report stated that R1 had missed administration of Medication #1 (M1) between 09/30/2025-10/03/2025. DOAL conducted a review of R1’s medications on 10/04/2025 and observed that M1 had not been given as prescribed since 09/29/2025. DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. LPA determined that further investigation into the missed medication administration is needed prior to determining if a citation is warranted. LPA informed ED that CCLD may return at a later date if it is determined that the issuance of a citation or assessment of a civil penalty is deemed warranted for this incident. ED expressed understanding and agreed to submit any relevant documentation to LPA for review. Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.