Facility Evaluation Report

Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced visit to the facility in conjunction with complaint control number 31-AS-20251203153637 . Upon arrival, LPA met with Staff #1 (S1), who granted access to the facility. The Administrator Designee was contacted and LPA explained the reason for the visit. The Designee arrived at 10:30 AM.

During the visit, LPA was informed that Client #1 (C1) refused to take her/his prescribed medication Vitamin D3 (50 mcg) on 11/29/2025 through 12/07/2025. However, LPA’s review of facility records and the Licensing database found no Unusual Incident/Injury Reports (LIC 624) submitted to the Community Care Licensing Division (CCLD) for either incident. During a telephonic conversation with the Administrator and an interview with the staff, they both confirmed that the incidents were not reported to the Regional Office (RO). Based on Title 22, Division 6, Section 80061(b), a written Unusual Incident/Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA reminded the Administrator that all staff members are mandated reporters and share responsibility for timely reporting of incidents that affect client health, safety, or well-being. LPA informed the Administrator to submit all unreported incident reports regarding C1 to CCLD and C1's Physician immediately.

Deficiency issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.