Follow-up·September 5, 2025

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to conduct an investigation and in conjunction, conducted this case management visit due to deficiencies found during the investigation. LPA identified herself and was granted entry by Elizabeth Lim, caregiver. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Licensee Cheryl Castro. During the Department’s investigation of complaint control # 08-AS-20250827145528, there were additional discrepancies found, which are being addressed during today’s visit. During the investigation, which consisted of interviews with staff, and residents, and records review of relevant documents, the investigation uncovered that the facility was not providing medication as prescribed, there is insufficient staff to meet the resident’s needs, residents are unable to leave their bedrooms after 6:00 PM, a resident who needed incontinence assistance was malodorous, and resident had dirty bedsheets. During today’s visit, LPA spoke with the residents (R2, R4, and R5), and staff #1 (S1) and staff #2 (S2) who confirmed that caregivers send residents to their room at 6:00 PM after their shift to rest for the night. According to interviews with residents and staff, S1 and S2 are the only caregivers who work at this facility and also reside at the facility. After review of records, it showed that S1 works at the facility from 6:00 AM – 12:00 PM and S2 works from 12:00 PM – 6:00 PM, which leaves the NOC shift unavailable. According to S1 and S2, they care for the resident after their shift if they require assistance throughout the night. Residents interviewed said they were not allowed out of their rooms after 6:00 PM but may yell for staff if they need assistance. During an interview of R3, LPA observed the resident to be malodorous of urine. LPA observed that the resident’s bedsheets were stained of dried fecal matter. (Continuation on LIC809-C) (Continuation of LIC809) According to staff, R3, had to be changed throughout the night because they had gone “poo poo.” While LPA spoke with the Licensee, they observed that the Medication Administration Records (MARs) had been compiled inside manila envelopes and LPA inquired how the staff are aware that they provide the medications to the residents. According to the Licensee, they write the medication timing on top of the bottle – either AM or PM or both. That is how staff know when the residents are to take the medications. LPA further inquired if they used the MARs and Licensee said no. LPA asked if bubble packs would be easier for staff and Licensee said that it would be more difficult for staff as there are too many packs to keep track of. LPA asked if they could demonstrate with one residents’ medication. When LPA opened two medications for R1 they found that medications were missing. There were two pill medications from one bottle missing and 5 pill medications from another bottle missing for R1 which LPA explained to the Licensee and counted in front of them. Based on the information obtained during the investigation, there are deficiencies observed and being cited during this visit and may be found on the LIC809-D page of this report . The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with licensee Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided to licensee Castro at the conclusion of the visit. The signature below confirms the receipt of these documents.