Incident investigation·April 2, 2024

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (AD), Jeff Moyer and Health Service Director (HSD) Karen Sutherland. The purpose of this visit is to follow up on an incident report submitted to the Fresno CCL office. It was reported that between 2/23/24 – 2/25/24 Resident (R1) did not receive as needed (PRN) medication as ordered. The facility did not update R1’s MAR to reflect the changes made by the hospice agency on 2/23/24. A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A Civil Penalty is being assessed for a repeat violation. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jeff Moyer, whose signature on this form confirms receipt of this document.