Non-compliance follow-up·March 11, 2026

On March 11, 2025 at 9:50am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on July 1, 2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Angelita Maravillas and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At 10:05am, LPA and Licensee conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. In bedroom #2 LPA noted two electrical outlets with no faceplates, leaving wires accessible. LPA and Licensee conducted a review of the facilities Centrally Stored Medications and Destruction Records (CSMDR) and the centrally stored medications for all three residents in care. During the review LPA and Licensee noted Resident #1 (R1) has a tube of triamcinolone 0.1% cream not logged on R1's CSMDR. Resident #2 (R2) with a bottle of quetiapine 25mg, pharmacy label states quantity thirty (30), instructions take one tablet by mouth every day, a physician order dated 11/12/25 states take one tablet by mouth twice daily and the CSMDR states this bottle was started November 2025 with no day noted. Had the medication been given as prescribed the medication from this bottle would have run out in fifteen days but a count of the pills in the bottle revealed eighty-six (86) pills, Licensee stated the reason there were more pills in the bottle (Contniued on LIC809-C) than the label stated was because they did not have enough pills and they took pills they had left over from a former resident and poured them into this bottle. A second bottle of quetiapine 25mg for R2 contained ninety (90) pills matching the quantity on the pharmacy label, the CSMDR for this medication states started on 3/8/2026. A review of Resident #3's (R3's) medication and CSMDR revealed a bottle of levothyroxine 75mcg with instructions to take one tablet by mouth every morning, a quantity of ninety (90) pills and start date of October 30, 2025; a count of the medications in the bottle revealed twenty-nine (29) dark blue pills with a stamp P3 indicating the pill dosage of 75mcg and three (3) light blue pills with a stamp P4 indicating 88mcg; Licensee stated R3's order changed from 88mcg to 75mcg and they must have combined the medications into this bottle; with a start date of October 30, 2025 at a quantity of ninety (90) this would be a ninety day supply. R3 also has a bottle of lisinopril 10mg with instructions take one tablet by mouth daily, and started on October 30, 2025; a count of the bottle revealed six (6) pills of the medication and a seventh pill with stamp of U25 matching R3's quetiapine 25mg bottle. Administrator stated they would destroy the medications that are mixed in bottles, stop using medications prescribed for other people, and ensure residents are receiving medications as prescribed. Exit interview conducted, deficiencies cited on LIC809-D pages, reports signed, and reports provided to Licensee.