Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management visit regarding deficiencies noted during a complaint visit conducted on 11/13/25 (Complaint #28-AS-20251113064315). LPA met with Administrator Luz Brillante and the purpose of the visit was discussed.

During LPA's inspection of refrigerator LPA observed medication (3 insulin boxes) to be stored inside the refrigerator that were unlocked and accessible to clients. Interviews with 5 clients, each client confirmed that they are able to access the refrigerator at all times to get a drink or snack which confirms these medications are easily accessible to the clients.

Per Title 22 regulation - 80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Based upon this observation and interviews, LPA Herrera will issue one (1) Type A Deficiency.

Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.