Facility Evaluation Report

At approximately 12:50 PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator/BOM Eugene Pascual, Executive Director, Terry Bechtold, & (HSD) Health Services Director, Tosha Chowdory. The purpose of the visit was to follow up on 3 self-reported incidents submitted to Community Care Licensing (CCL).

On 8/29/2025 CCL received 3 unusual incident reports regarding 3 different residents (R1)(R2)(R3) who missed some of their medications : (R1) 8/21- 24/2025, (R2) 8/21-25/2025, & (R3) 8/22-25/2025 due to not arriving in pharmacy routine cycle. Per conversation with HSD on 8/19/25 facility received monthly medications for residents finding 25 residents missing medications, contacted pharmacy requesting missing medications. Cycle starts on 8/21/25 and most of the missing medications had arrived. Staff did not notice the 3 residents still missing medications or notify doctor, hospice, or family until 8/24 & 8/25. Residents were put on 72 hour monitoring, none were observed to have any adverse side effects. Retraining on cycle fills and reordering process to ensure timely and accurate medication management was conducted. Nursing to now follow up on all pharmacy communication along with a medication refill binder has been implemented for review at each shift change. LPA obtained new plan, disciplinary action, & training at visit.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided