Health check·June 4, 2025

On 06/04/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visit due to non-compliance concerns discussed during a Microsoft team meeting on 01/30/25. LPA Lee met with administrator Marie Taylor Trimmingham and explained the purpose of the visit. The census is 6 with 2 facility staff. LPA Lee and administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed 5 resident bedrooms, 2 resident bathrooms, common area, staff room, kitchen, laundry room and the courtyard. LPA Lee observed resident bedrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms handrails and non-skid mats are in good repair. Fire extinguishers were up to date and fully charge. No emergency exits were obstructed. LPA Lee reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPA observed laundry room where it was observed that detergent was locked and made inaccessible at this time. Knives were observed to be locked and made inaccessible. LPA Lee inspected the garage and observed the garage not locked and cleaning supplies are stored in the garage and multiple cleaning supplies was made accessible to residents in care. During today’s visit administrator removed the cleaning supplies from the garage to a locked cabinet. LPA Lee requested to review 3 resident files and 2 staff files, and they and it was observed to be current with up to date. LPA Lee reviewed 3 resident medications, and 2 out of 3 resident’s medication was incomplete. Resident 1 (R1)’s Docusate medication was not given per doctor’s order. R2 Losartan Potassium medication was also not listed in the MAR logs with R2’s other medications. An audit of R2’s Losartan medication revealed that R2’s Losartan medication is over by 1 count. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with administrator Marie and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.