Non-compliance follow-up·May 29, 2025

Licensing Program Analysts (LPAs) Martha Arroyo, Valeria Conway, and Kelly Dulek along with Licensing Program Manager (LPM) Kristen Heffernan conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs and LPM met with Executive Director (ED), Monica Reyes and explained the reason for the visit. The LPAs and LPM focused today’s visit on ensuring medications are in order and in compliance with Title 22 Regulations. During today's visit, the LPA conducted a medication review starting at 1:00 p.m. The following was noted: On 05/14/2025, the Centrally Stored Medication and Destruction Records (CSMDR) and medications for Resident #1 (R1) were reviewed. The review revealed that the PRN medication Lorazepam 0.5 mg, 1 tablet up to 2 times per day as needed, was filled on 03/27/2025. However, the medication had not been administered to R1, as staff were unable to locate it. During today’s visit, a follow-up medication review revealed that the facility still had not received the Lorazepam for R1. Furthermore, staff were unable to provide documentation indicating that the medication had been reordered since the last review on 05/14/2025. As a result, R1 is not receiving the prescribed medication because it is not available on-site. Staff reported that they had contacted the pharmacy to place an order, but they were unsure why the medication had not been delivered. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided. This report has been amended to include a civil penalty of $1,000 due to repeat violation of Section 87465(a)(4) as it has been cited three times within 12 months - 10/10/2024, 04/29/2025, and 05/16/2025.