Follow-up on corrections·November 19, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:14 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett and the Director of Assisted Living (DOAL) Yamilette Capilla entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 10/04/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), reviewed Resident #1’s (R1) medication administration record (MAR), and collected copies of pertinent documentation between approximately 10:20 AM and 11:48 AM. 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. On the 11/06/2025 visit to the facility the DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. During today’s visit the facility was unable to provide documentation of the physician’s orders to hold administration of M1. LPA observed R1’s MAR to contain entries of administered M1 between 10/05/2025 to 10/16/2025. LPA did not observe MAR entries for R1’s M1 administration between 09/30-10/03. LPA observed a physicians order to hold M1 administration dated 10/09/2025, LPA did not observe any further orders to resume M1 administration. DOAL informed LPA that the entries were not cleared at the time of the administration and were cleared at a later date by a different med tech. DOAL stated that because of this, notes were unable to be added noting that the medication was not administered on those dates. DOAL provided LPA with signed statements from the Med tech on duty and the med tech that cleared the entries stating that M1 was not given to R1 on 10/16, 10/15, 10/10, or 10/09. LPA informed the ED and DOAL that they were recently cited for a violation of CCR 87465(a)(4) on 10/01/2025. LPA informed ED and DOAL that a civil penalty in the amount of $250 is being assessed on today’s date (11/19/2025) for a repeat violation of the same licensing regulation within a twelve (12) month period. DOAL stated that med techs and nurses had been given mandatory training on 11/13/2025 which included a review of title 22 regulations regarding medication management and the importance of adhering to policies and procedures regarding medication administration/tracking. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency and civil penalty were cited (refer to LIC 809-D): Exit interview conducted with DOAL and copy of the report was issued and appeal rights provided.