Facility Evaluation Report

LPA Carol Fowler arrived on 6/03/2025 at 11:00am, attempted to conduct a Case Management visit regarding an incident that was reported to CCLD on 5/28/2025. There was no one at the facility. LPA later spoke with Banaag Yamsun and LPA was informed that residents are at day program and staff was out grocery shopping.

On 6/03/2025 at 1:45pm, Licensing Program Analyst (LPA) Carol Fowler conducted an announced Case Management visit regarding an incident that was reported to CCLD on 5/28/2025. LPA met with Paul Rivera, Lead Care Giver and explained the purpose of the visit.

The incident reported occurred on 5/27/2025. The report stated on 5/27/2025, S2 administered the wrong evening medications to R1 from R2 medications box. After S2 realized the error, S2 immediately notified R1's PCP and nursing manager in charge (S3). The PCP instructed S2 to withhold all evening medications and monitor vital signs every 15 minutes and overnight and report any deviations from R1's baseline.

The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties

Exit interview conducted. A copy of this report provided.