Facility Evaluation Report

Licensing Program Analysts (LPA’s) Mariana Agban and Evelin Rios conducted a Case Management - Deficiency visit in conjunction to Complaint Control Number 31-AS-20251024154115. LPAs were granted access by caregiver and met with Assistant Administrator, Sean V. Abalajon shortly after. LPAs explained the reason for the visit.

During the physical plant inspection, LPA Rios observed medications stored in two (2) of the six (6) resident bedrooms. A review of all six (6) residents’ records revealed that Resident #2’s (R2’s) Physician’s Report (LIC 602) indicates R2 as unable to manage or store their own medications. Resident #3 (R3) had an incomplete LIC 602 that did not specify whether they are capable of storing their own medications. In an interview, the Assistant Administrator stated that R2 “chooses” to keep their medications, and there for the facility allows it. They also informed LPA Rios that R3 has a diagnosis that could pose a health and safety risk if R3 were given access to their medications.

During the physical plant tour, LPA Rios observed a medication organizer in R2’s bedroom, as well as another organizer in the facility’s medication cabinet. Several small containers filled with various pills were also observed. According to the Assistant Administrator, medications for Residents #1 (R1) and R2 are arranged in weekly organizers due to the volume of medications they require. For the four (4) other residents, medications are placed into small containers labeled “AM” and “PM” to provide scheduled medication.

A review of the facility’s medication management policy revealed that all medications are required to be locked, centrally stored, and kept inaccessible to residents. Additionally, the policy states that medications must be prepared by staff in a medication cup one hour prior to administration, in accordance with physician orders.