Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management-Deficiencies visit at the facility at 12:31 AM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 12:35 PM entrance interview was conducted and the reason for the visit was explained.

During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) staff file, conducted a medication audit for one (1) resident and conducted interviews with the Administrator, one (1) staff, and two (2) residents between 12:31 PM and 02:54 PM.

During the visit LPA reviewed Staff #1’s (S1) file. LPA did not observe S1 to have appropriate training pertaining to handling resident medications. LPA conducted an interview with S1 where they admitted to administering medication to Resident #1 (R1) on the morning of 09/24/2025. S1 also stated that they observed Staff #2 (S2) administering medication to R1 on two (2) separate occasions. LPA attempted to review S2’s file but the Administrator was unable to provide S2’s file to LPA for review during the visit. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR). LPA did not observe R1’s CSMDR to have Medication #1 (M1) appropriately logged.

The following deficiencies were cited (refer to LIC 809Ds). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.