Follow-up·July 10, 2025

At 9:15am on 07/10/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Serious Incident Reports (SIR) from the facility, reviewed from March 2025 through June 2025. Upon arrive to the facility and entering at 9:15am there were no staff at the entrance, LPA singed in and walked into the facility. LPA walked down to the left side hallway and discovered the Med room unlocked and unattended. LPA called Administrator by phone and left a message on Administrators cell phone. LPA met with Resident Care Coordinator, Veronica Guinea (RCC), , announced who he is and the reason for the visit. LPA Jeffries took a short video of the unsecured medication room searched and found staff and asked staff to secure medication room. LPA noted that there were 5 residents in the dining room and 2 residents walking the hallway near the medication room when LPA discovered the unsecured and open medication room. LPA called Administrator on cell phone to request her presents at the facility at 9:30am. Facility will receive citation, 87465(h)(2) Incidental Medical and Dental Care, medications accessible to persons other than responsible employees. LPA Jeffries reviewed SIR's from the facility during the months of March 2025 through June 2025 and noted at least 18 SIR's with late and/or missing information as required by Community Care Licensing (CCL) Regulations 87211. LPA Jeffries noted that there were two verbal warning by LPA Jeffries to Administrator, Robin Murray about regulation reporting requirements of SIRs being submitted past the 7 days within the occurrence to report regulation requirements (87211(a)(1)), on 04/03/2025 and 04/30/2025. CONTINUED on LIC809-C LPA Jeffries followed up with an written warning of late SIRs in an email sent to Administrator on 06/18/2025, and followed up with an email to Administrator of copy of CCL 87211 reporting requirements sent to Administrator on 06/20/2025. In reviewing SIRs dated from March 2025 through June 2025 LPA noted that there were 105 SIRs submitted by the facility. 18 of 105 were submitted after the 7 day requirement. LPA also noted that 7 of 105 SIR's had no attending physician's name, findings, and treatment, if any; and disposition of the case when residents had returned from the Emergency Room (ER) visits. On 07/03/2025 LPA requested ER discharge paperwork for an incomplete SIR dated 06/24/2025. LPA noted that the ER discharge paper work was incomplete and contacted Administrator on 07/02/2025 by phone to reviewed CCL Regulations reporting requirements. Based on 18 of 105 SIRs in March 2025 through June 2025 being submitted past 7 days of the occurrence, and 7 of 105 SIRs review during that time not having attending physician's name, findings, and treatment, if any; and disposition of the case when residents returned from the Emergency Room, a citation is issued. Exit interview, report read, appeal rights and report provided.