Incident investigation·July 1, 2025

Licensing Program Analyst (LPA) Vincent Moleski and Office Technician Amy Jordan arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. LPA Moleski reviewed a death report which described the death of a resident (R1) on 6/17/25. R1 was awake and alert around 6:30 a.m., but was found unresponsive shortly after taking their morning medications, according to the report. LPA Moleski reviewed R1's file and interviewed Barias. LPA Moleski counted out R1's overactive bladder medication and observed that there were not enough doses of the medications to account for the number of pills remaining in the bottle. LPA Moleski counted 59 pills remaining in the 200-count bottle, which should correspond with 141 recorded dosages. However, there were fewer than 141 doses recorded in R1's MARs, and even counting every day R1 was present in the facility, there were not enough possible doses between the date the bottle was opened, 4/1/25, and R1's date of death, 6/17/25, to account for 141 doses, presuming that prescription orders were followed. Vidan observed the medication count to ensure accuracy and agreed that there was a discrepancy. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.