Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Elena Mallett conducted a Case Management Visit-Incident on 10/10/2025, stemming from Special Incident Report received on 09/26/2025. LPA was greeted by Administrator Jeanette Marrujo and explained the purpose of the visit. Quality Assurance Director Claudia Lujan arrived shortly after to assist.

According to incident report dated 09/25/2025, staff#1 (S1), reported to Administrator Marrujo on 09/25/25 at 5pm, that client#1 (C1) was not administered eleven (11) of their AM medications. C1’s primary care physician (PCP) was notified and advised staff to closely monitor C1 for any possible side effects. Staff later reported C1 did not have any adverse reactions. Later than day, Administrator Marrujo conducted a re-training on medication administration for all staff.

On 10/09/2025, S1 was given a corrective action report and counseled on the importance of administering medication according to the physician’s order. On 10/09/2025, additional training was conducted on medication administration and error prevention for all staff.

On 10/10/2025, LPA Ramirez conducted staff interviews and reviewed records. Interview with Administrator Marrujo revealed the facility requires that all medication administered be re-verified by a second member of staff. Staff#2 (S2) did not verify C1’s medication was administered. Administrator Marrujo revealed that both S1 and S2 received corrective action reports and counseled on the importance of administering medication according to the physician’s order.