Incident investigation·August 28, 2025

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 2:30 p.m., the LPA met with staff and explained the reason for the visit. At 2:37 p.m., the Executive Director (ED), Jovany Guerra met with the LPA. The reason for today's visit is to follow up on a self-reported incident report dated 08/08/2025. The report pertains to Resident #1’s (R1’s) missing narcotic medication. The report states that R1’s missing medication was replaced by the pharmacy and that there was no delay in medication administration. The report also noted that disciplinary action was taken against Staff #1 (S1) for the medication error. During today’s visit, at 2:37 p.m., the LPA conducted an interview with the ED. At 2:45 p.m., the LPA requested and obtained copies of pertinent documents. At 3:25 p.m., the LPA, along with the ED conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.