Facility Evaluation Report

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Case Management Visit to follow up on a special incident report (SIR) we received on 04/20/26 and 04/24/26. LPA was met by Administrator Marsha Murray and Assistant Administrator Tracey Mitchell explained the purpose of the visit.

LPA Gutierrez received SIRs for client #1 -client #2 (C1-C2)) indicating there were medication errors. On 04/19/26 it was observed during a medication check that on 04/17/26 C1’s Simvastatin 40 MG nighttime dose was not administered and still in the bubble back and on 04/23/26 staff observed C1’s Sulfasalazine 500 MG was administrated at 8:00 AM instead of the required time of 12:00 PM. On 04/19/26 during a medication check it was observed that on 04/17/26 C2’s Quetiapine 50 MG 8:00PM nighttime medication was missed and still in bubble pack.

During today's visit LPA spoke with Administrator and Assistant Administrator about the errors and what facility was doing to ensure staff was in medication compliance, LPA also obtained staff roster, reviewed staff #1 and staff #2 file and obtained copies of corrective actions plans for both S1 and S2.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.