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Inspection visit

Follow-up on corrections

CARRIES CARE VILLALicense 1976097823 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management-Deficiencies visit at the facility at 12:31 AM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 12:35 PM entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) staff file, conducted a medication audit for one (1) resident and conducted interviews with the Administrator, one (1) staff, and two (2) residents between 12:31 PM and 02:54 PM. During the visit LPA reviewed Staff #1’s (S1) file. LPA did not observe S1 to have appropriate training pertaining to handling resident medications. LPA conducted an interview with S1 where they admitted to administering medication to Resident #1 (R1) on the morning of 09/24/2025. S1 also stated that they observed Staff #2 (S2) administering medication to R1 on two (2) separate occasions. LPA attempted to review S2’s file but the Administrator was unable to provide S2’s file to LPA for review during the visit. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR). LPA did not observe R1’s CSMDR to have Medication #1 (M1) appropriately logged. The following deficiencies were cited (refer to LIC 809Ds). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87411(d)(4)Type B

    87411 Personnel Requirements - General(d) All personnel shall be given on the job training...(4) Knowledge required to safely assist with prescribed medications...This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as S1 admitted to dispensing medication to R1 without appropriate medication training which poses a potential health and safety risk to clients in care.

  • 87412(g)Type B

    87412 Personnel Records(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as S2's file was missing from the facility which poses a potential health, safety, or personal rights risk to clients in care.

  • 87465(h)(6)Type B

    87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record...is maintained...This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R1's CSMDR was missing an accurate log of M1 which poses a potential health risk to clients in care.

  • 87465(a)(4)Type A

    87465 Incidental Medical and Dental...(a) A plan for incidental medical and dental care shall be developed...by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed...This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee did not comply with the section cited above as R1's M1 medication was not administered as prescribed by their physician on at least 3 separate occasions with at minimum 7 pills missing which poses an immediate health risk to clients in care.

FAQ · About this visit

Common questions about this visit

What happened during the September 24, 2025 inspection of CARRIES CARE VILLA?

This was a other inspection of CARRIES CARE VILLA on September 24, 2025. 3 citations were issued: 3 Type B.

Were any citations issued to CARRIES CARE VILLA on September 24, 2025?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: "87411 Personnel Requirements - General(d) All personnel shall be given on the job training...(4) Knowledge required to s..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.