Incident investigation·January 27, 2026

Licensing Program Analysts (LPAs) Christi Coppo and Ethel Contreras arrived at this facility unannounced to conduct a case management visit and was greeted by caregiver. Licensee on site but was not inside facility when LPA arrived. Licensee arrived inside facility later. LPA met with licensee Alex Varshavsky. Upon entering the facility LPA observed caregiver alone in medication room. LPA asked if licensee was here and S3 responded yes but that they did not know where he was at, he was “some place around the facility.” LPA then observed S3 to exit the med room carrying a tray of medications. LPA asked S3 if they were going to pass the medications on the tray and S3 responded yes. S3 went on to start passing the meds on their own without licensee. LPA waited for licensee in the dining room. Licensee showed up about 15 minutes later. LPA asked licensee if S3 had completed their medication training in order to pass medications on their own. Licensee responded that he was still training S3. LPA asked licensee for S3’s medication training. LPA reviewed S3’s training records. LPA observed medication test present in S3’s file. LPA observed 1 hour of “Understanding California Medication Regulations,” completed on 2/21/25. No other documentation of medication training present. ( deficiency cited, see 809D ). On 1/13/26 facility submitted an Incident Report (IR) for resident (R1) indicating that on 1/8/26 R1 was sent to the doctor and then the emergency room. However, IR did not indicate the nature of the event, symptoms exhibited or any cause for sending R1 to the emergency room, report did not provide description of any findings or treatment if any occurred at the hospital, or when/if R1 returned to the facility. On 1/23/26 facility submitted an IR for resident (R2) indicating that on 1/23/26 R2 was sent to the emergency room. However, Continued on 809C... Continued from 809... IR did not indicate the findings or treatment if any occurred at the hospital nor did it indicate whether or not R2 returned to the facility. On 1/23/26 facility submitted an IR for resident (R3) indicating that on 1/18/26 R3 was sent to the emergency room. However, IR did not indicate the findings or treatment if any occurred at the hospital, nor did IR indicate whether or not R3 returned to the facility. Attending physician's name not listed on any of the IRs submitted. Per regulation 87211, the facility is required to submit an IR to CCL for any incident, including but limited to, those which threaten the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Additionally, the report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. LPA discussed Reporting Requirements regulation with licensee and importance of submitting complete reports in compliance with regulation 87211, including the findings, treatment, and disposition of the incident being reported.