Non-compliance follow-up·June 26, 2025

Licensing Program Analyst (LPA) Teresa Camara conducted a case management legal/non-compliance visit. LPA met with Clinical Director David Rivas, RN, and explained the reason for the visit. LPA's focus during this visit was to audit medications. LPA reviewed medications for Resident 1 (R1) and found the following: The centrally stored medication and destruction record (CSMDR) was missing the start dates on nearly all of R1's medications. Some of the medications are "on cycle" meaning they were started on the first of each month but some of R1's medications are not "on cycle" meaning they were started on different dates which were not noted on the bubble pack nor were they noted on the CSMDR. One of the medications was started on cycle. The medication administration record stated the medication was given each day but there were still pills in the bubble pack for 6/5,6,7,10,17/2025. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. An immediate civil penalty of $1,000 is assessed for a repeat violation within one year. Failure to correct the deficiencies may result in further civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.