Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit to note deficiencies observed during a complaint investigation visit conducted on 4/22/25 by LPA Mary Flores. LPA met with Lakeisha Ogesby and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings.

· On 4/22/25 LPA Flores conducted a complaint investigation visit. During the visit LPA reviewed 5 residents’ medication around 12:00pm and found that in 3 out of 5 residents, resident #2,#4 and #5(R2,R4,R5) staff had initialed in the PM/evening section of 4/22/25 for dose needed to be provided in the afternoon. Per administrator, staff initial medication sheet once the medication is provided and medication was still in package and not provided to the residents.

· On 4/22/25 LPA Flores interview administrator and staff who stated Resident #3(R3) had gone out to the hospital in January of 2025 via emergency responders (911) as R3 had been feeling ill. Per administrator, did not submit an incident report as administrator did not know it was reportable to Community Care Licensing (CCLD).

Deficiencies are noted on LIC 9099D per Title 22 Regulations.

Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 809D, and appeal rights were provided.