Follow-up on corrections·October 9, 2025

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open a complaint, but discovered an unrelated deficiency during the course of the investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2). In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25. LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month. [continued 809-C] LPA Moleski reviewed a fax sent to R1's prescriber dated 9/29/25 reporting the error. The fax stated that R1 received an order to increase a different order for the same medication on 9/18/25. "However, the order was not transcribed correctly," the fax read. "As a result, the existing order ... was inadvertently discontinued. This led to [the medication] being missed from 9/18/2025 at 10:00 a.m. until 9/25/2025 at 12:00 p.m." In an interview, S2 admitted to incorrectly transcribing the report. LPA Moleski reviewed fax and email records and observed that no incident report was received by the Community Care Licensing Division (CCLD) regarding this error. S2 said that no incident report was sent to CCLD. 22 CCR Section 87211(a)(1)(D) requires that licensees report "any incident which threatens the welfare, safety or health of any resident..." This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.