Facility Evaluation Report

On 03/20/2026 Licensing Program Analyst arrived at the facility to complete an unannounced Case Management visit. LPA met with Administrator, Soccorro "Ann" Telmo, explained reason for visit and was permitted entry into the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 6 residents present during todays visit. There are currently no residents who receive hospice services or are bedridden.

This case management is being conducted from a complaint visit occurring on 2/21/26.

During this visit LPA observed a conversation between R1 and S1. S1 was informed by R1 that they "overdosed" on medication. Interview with S1 disclosed that family of R1 picked up a prescription (Metformin 500 mg tablet 2x daily by mouth) from the pharmacy and provided the medication to R1. S1 stated they were unaware family already provided the medication to R1. S1 provided R1 the medication a second time. R1 received 1000 mg in am instead of 2x's daily as prescribed. Review of incident reports for the facility does not disclose there was a medication error on this date for R1.

During the annual visit being conducted on 3/20/26, a medication audit was completed. The audit disclosed that R2 also has medication errors. Review of medication record disclosed R2 has prescription for the following medications:

1) Carvedilol 3.125 mg tablets 2x daily. Prescription states that medication is to be held if BP is<110/HR<60. Review of record does not show that R2 had their BP taken on 3/8/26 and 3/12/26.

2) Sertraline 25 mg tablets 1x daily. Medication started on 3/7/26. Review of records/medication show the prescription is missing 1 tablet. S1 and Administrator is unaware what occurred.

3) Tramadol HCL 50 mg tablet as needed for pain 3x daily. Medication started on 2/26/26. Review of record/medication shows 3 tablets are missing.

4) Lisinopril 2.5 mg tablets 1x daily. Medication started 2/16/26. Medication audit show medication ran out on 3/17/26 and was not provided to R2 on 3/19/26 and 3/20/26 and a refill has not been received.

Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct risk to the health, safety and/or personal rights of residents in care.

Exit interview was conducted with Administrator, Ann. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to Administrator.