Follow-up·November 15, 2024

On 11/15/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management visit at the facility listed above. LPA met with the Co-Executive Director Gloriella Jara (S1) and explained the purpose of the visit. On 10/11/2024, LPA requested for Medication Administration Records from S1. On 10/24/24, a follow up email was sent to former Executive Director Michael Mendoza requesting the 10/11/24 documents plus additional information. On 10/25/24, S1 sent Medication Administration Records. On 11/08/24, LPA conducted a subsequent complaint visit for control number 11-AS-20241003141025. Staff #2 (S2) and Staff #3 (S3) informed LPA that some medication is recorded on a separate Controlled Medication Count document. LPA requested for April 2024 – November 2024 Controlled Medication Count records for five (#1 - 5) specific residents. S2 and S3 indicated that the documents are removed monthly and placed in storage. However, S2 indicated that S2 would start gathering the documents on hand to be emailed. On 11/12/24, LPA sent a follow up email to S1, S4, and S5 requesting for the documentation. On 11/15/24, LPA conducted a case management visit for control number #11-AS-20240702154711 and LPA followed up on the requested documents. S1 requested for additional time since S5 is no longer with the facility and S4 is away on vacation. S1 indicated that the documents can be provided on 11/18/24. A technical violation is being issued, see LIC9102. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. A copy of this report was discussed and a hard copy of LIC809, LIC9102, and LIC811 was provided to Co-Executive Director Gloriella Jara.