Non-compliance follow-up·April 27, 2026

On 04/27/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was greeted by Facility Designated Administrator (FDA), Andrea Armstrong and explained the purpose of the visit. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors. During today's visit, LPA Pascua conducted a tour of the Assisted Living, kitchen, outside areas, and memory care unit. It was learned during the course of this tour that this facility has 3 caregivers, 1 medication technician, and 1 activity director in each memory care and assisted living areas. In addition, the assisted living units have an additional activities aid and facility driver. LPA Pascua reviewed the Medication rooms in both the Assisted Living and Memory Care areas. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. It was observed by this LPA that on PRN and daily logs have been completed and dated by the Medication Technician as of this date, 04/27/2026. In addition, medication has been logged and accounted for during medication pass at 1:12pm. A review of the assigned tasks and duties for caregivers to complete for all three shifts for memory care and assisted living(AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. It was observed that the facility staff did not properly fill out and initial into this binder when the assigned tasks had been completed for book #1 and Book#2. Book #1 did not have initials in this binder for 04/15 NOC shift, 04/20 AM shift, and 04/21 NOC shift. Book #2 did not have initials for 04/15 PM shift and 04/21 NOC Shift. A review of the memory care logs were conducted. In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of April 2026 was reviewed by this LPA. It was observed that entries for R1 had not been completed logging bowel movements for 04/23, NOC and PM shift, 04/25 AM shift, and 04/26 for NOC shift. All other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that the facility has implemented Safely You monitoring in all memory care units. LPA Pascua conducted a test of the facilities delayed egress system. A facility log book also was reviewed which documented the facilities daily check of the locked doors. The following documentation was requested to be submitted to this LPA by 05/01/2026 by 5:00pm -Last medication audit conducted by the partnering pharmacy -Staffing schedule for the March-April 2026. -Medication Training past 3 months has been sent via email to arielle.pascua@dss.ca.gov for review -Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any in services related to the above over the past 3 months to be sent via email to arielle.pascua@dss.ca.gov for review The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit interview.