Follow-up on corrections·October 16, 2025

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20251001111956 . During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA is also following up on an incident report received on 10/16/2025. LPA met with Acting Director of Health Services Scott Self Wile investigating the complaint 26-AS-20251001111956, regarding R1, LPA noted issues in resident R1's Care plan. The Department reviewed resident R1’s Progress notes. Progress note dated August 7, 2025 states around 2:30pm, R1 had an unwitnessed fall in his/her bathroom. R1 claimed he/she slipped when trying to use his/her toilet. R1 was able to move all extremities without pain, no complaints of pain, no visible bruises. Progress note dated September 27, 2025, R1 had an unwitnessed fall around 1:40pm. Staff brought resident to his/her room to rest on recliner, then 10 minutes later, a thud was heard. Staff checked on R1 and found him/her next to recliner. Resident was assisted, and no injuries noted. On October 6, 2025, the Department received an incident report regarding R1, dated September 27, 2025. The incident report stated, on September 27, 2025, around 1:40pm, R1 was found sitting on the floor next to his/her chair. R1 stated he/she lost his/her balance and fell. Hospice noticed a small lump on the right side of head. R1 denies pain. R1’s POA was notified and stated he/she didn’t want R1 to be sent to the hospital. Based on a review of R1’s Physician's Report, dated June 3, 2025, R1 has a neurocognitive disorder. R1 requires assistance with repositioning and transferring. The Department reviewed R1’s Needs and Services Plan, Dated August 30, 2024. The Care plan states R1 needs to be escorted back to room after activity as needed. Remind resident to ask for assistance when the need for toileting comes. Assist with lowering and raising of clothing. Based on a review, this care plan was not updated to address R1's requiring assistance with transferring and does not detail a plan to address R1's recent falls prior to September 28, 2025. Incident Report October 11, 2025 On October 16, 2025, the Department received an incident report regarding resident R2. The incident report stated, on October 11, 2025, at 9:00pm, the family of R2 brought a new prescription, medication M1. Family did not inform medtech they had already given dose to resident when they arrived. Med tech started the medication and resident was given a double dose within an hour. On October 16, 2025, LPA interviewed Acting Director of Health Services Scott Self, (HS). HS stated the medtech did not follow procedures when receiving a new medication. HS stated the medtech did follow facility procedures, and did not do a physical count of the medication that just arrived, before administering the medication. HS stated they are doing an in-service today regarding medication administration guidelines and receiving medication administration. Based on a review of R2's physician's report, dated, March 13, 2025, R2 cannot store or administer his/her own medications. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Acting Director of Health Services Scott Self and a copy of the report and appeal rights were provided.