Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit to address observations made during a Complaint Investigation dated 7/1/2025, complaint control # 28-AS-20250627115520. LPA met with Administrator Rowena Santos and explained the purpose for todays visit.

During visit dated 7/1/25 LPA conducted a medication review and the following was observed:

The Medication Administration Record (MAR) was not being documented properly as June 29-30, 2025 and July 1, 2025 were not signed for by the staff that assisted with administering medications each of those days for all residents, LPA spoke with S2 and S2 stated they did give the medications per doctors orders they just forgot to sign MAR.

LPA observed R1’s medication list provided by the doctor, there were PRN medications listed (as needed medication), however, those medications were not in R1’s Medication basket, when LPA questioned S2 about this medication they stated they have not refilled the medication for R1.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are documented on 809D. Exit interview held, a copy of the report and appeal rights were provided.