Incident investigation·May 14, 2026

On 05/14/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a case management visit regarding an incident report received by the Department. LPA Lee met with Health Services Director (HSD) Katelyn Flores and explained the purpose of the visit. On 04/09/2026, the Department received an LIC 624 Incident Report regarding an incident that occurred on 04/07/2026 involving Resident 1 (R1)’s medication. LPA Lee reviewed the incident report and learned that R1’s Hydrocodone medication, which had been delivered on 04/02/2026, was missing from the narcotic drawer. The facility conducted an internal investigation regarding the missing medication. Per HSD Flores, the medication was delivered from the pharmacy and hand delivered to Medtech, who signed and acknowledged receipt of the medication. HSD Flores stated that two (2) Medtechs then observed and counted the quantity of the medication and logged it into the medication inventory log. According to the facility’s investigation, there was no documentation indicating that the medication had been destroyed or signed out to family members or physicians. Per the facility’s investigation, it was determined that Staff 1 (S1) may have taken the medication. It was further learned that S1 may have ripped and attempted to shred the medication inventory log and narcotic count sheet. The incident was reported to law enforcement and the resident’s physician, and the police report number was provided to the physician. Per HSD Flores, narcotic medications are inventoried every shift (three times daily). CONTINUED LIC 809-C However, the facility was unaware that the medication was missing because the medication inventory log and narcotic count sheets were also removed and destroyed. The issue was only discovered when another Med-Tech questioned HSD Flores regarding the medication, as the staff member had been present when the medication was delivered on 04/02/2026. This resulted in a lapse in the facility’s narcotic medication auditing process. As a result of this case management visit, the facility was found to be out of compliance with Title 22 regulations. The deficiency is cited on the attached LIC 809-D page. An exit interview was conducted with HSD Flores and copies of the LIC 809 report, LIC 809-D page, and Appeal Rights were provided to the facility representative. Failure to correct the deficiency may result in civil penalties.