Complaint·August 27, 2025

Page 2 of 3. Facility staff did not properly maintain centrally stored medications. / Facility staff did not maintain accurate medication records for residents. It was alleged that the facility staff do not maintain medications. It was alleged that the facility staff do not record resident’s medications on the centrally stored medication log. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there are no issues with properly maintaining centrally stored medications. Two out of two staff stated they have not seen or heard staff express issues with medication management. Two out of two staff stated there are no issues with the residents’ centrally stored medication log. Two out of two staff stated the staff initial their names next to the medication they have logged on the document. Based on review of residents’ records at random, 4 out of 4 resident’s LIC 622 Centrally Stored Medication and Destruction Record were not maintained accurately to document the start date of a medication and/or medication was not recorded. LPA Rai reviewed R1’s LIC 622 and observed 3 out of 4 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R2’s LIC 622 and observed 5 out of 7 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R4’s LIC 622 and observed 10 out of 12 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R3’s LIC 622 and observed 5 out of 12 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. During the inspection of R3’s room, LPA Rai observed 7 out of 12 medications in the resident’s room, accessible to the resident. Based on review of R3’s Physician’s Report dated 5/19/2025, R3 cannot administer and store medications. S2 was present during the inspection of R3’s room and S2 stated they will assess resident and obtain physician’s order for R3 to administer and store medications. Page 3 of 3. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. On 7/11/2025, LPA Rai cited deficiencies from California Code of Regulations, Title 22 87465(h)(2) and 87465(a)(4) under Incidental Medical and Dental Care. Plan of Correction was submitted in a timely manner. During today’s visit, LPA Rai cited deficiencies from California Code of Regulations, Title 22 87465(h)(6) under Incidental Medical and Dental Care regarding the facility staff did not maintain accurate medication records, such as LIC 622 Centrally Stored Medication and Destruction Record for 4 out of 4 resident records. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator, Jasmine Latu and a copy of the report was provided. Appeal Rights were provided. Page 2 of 3. Licensee did not ensure sufficient staffing to assist residents with medications. It was alleged that the facility does not have a staff trained to administer medications during the night shift (10pm-6am). On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the facility staff assigned to administer and manage medications are called Medication Technicians (Med-Techs). Two out of two staff stated there are 2 Med-Techs in the Am shift (6am-2pm), 2 Med-Techs in the PM shift (2pm-10pm) and 1 Med-Tech in the night shift (10pm-6pm). S2 stated he/she has worked as a Med-Tech to cover shifts and S2 will ensure all shifts are covered. Based on review of staff schedule for 4/1/2025-06/30/2025, there was at least one med-Tech scheduled each day for AM shift, PM shift and night shift. LPA Rai did review S2 covered Med-Tech shifts certain days of the month. Licensee did not ensure staff dispensing medication to residents was appropriately trained. It was alleged that the facility staff are not trained to administer medications. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the Med-Techs are provided 8 hours of theory training and 16 hours of shadow training. S2 stated there is additional training for staff in necessary. On 7/10/2025, LPA Rai obtained staff training records at random for 3 Med-Techs. On 8/27/2025, LPA Rai obtained staff training record at random for additional 3 Med-Techs. Based on review of staff training for 6 staff (S1-S6), 6 out of 6 staff have obtained training necessary for administering medications to residents. The training topics provided to staff included but not limited to “Basics of Medication Management”, “Medication Documentation for California”, “Providing Medication Assistance – California” and “Documenting Medications”. Page 3 of 3. Facility staff did not safeguard the confidentiality of residents’ records. It was alleged that the facility staff did not safeguard the confidentiality of residents’ records which are kept in binders accessible in residents’ rooms. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the resident’s records are in the office which is locked. Two out of two staff stated the electronic medication record (EMR) is updated with all the resident forms. S2 stated the hospice binder is located in the resident’s rooms. On 7/10/2025, LPA Rai toured the resident rooms at random, 2 out of 2 residents under Hospice services had binders in their rooms. LPA Rai reviewed the documents in the binder and they were documents with resident’s information. LPA Rai observed that both rooms were locked. S2 stated the residents’ rooms are locked from the outside and the perspective residents and the facility staff have access to the locks. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Jasmine Latu and a copy of the report was provided.