Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conducted an unannounced case management deficiency inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Rose Martellotti and explained the reason for the inspection.

The regional office received an unusual incident report on February 27 th , 2025 regarding an incident that occurred on February 25, 2025. The report stated that Staff #1 (S1) administered the wrong medication to Resident #1 (R1) on this date. S1 informed Staff #2 (S2) of the incident right away and S2 called R1s doctor and responsible party. S1 monitored R1 to ensure that no side effects took place every 3 hours for 12 hours. A medication training was taken place with S1 in attendance.

LPA toured the facility, gathered necessary documentation, and conducted interviews with S1, S2 and R1. During interviews S1 and S2 stated that S1 administered the wrong medication and that R1 was monitored per doctors order. R1 stated that they were okay and did not feel any side effects from the medication given.

Upon file review LPA observed the daily log that showed R1 being monitored with their vitals being taken every 3 hours for 12 hours. S2 held a three hour in service training and LPA observed that S1 attended the training via the training log sign in sheet on February 26, 2025.

Based on today’s inspection a type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Rose Martellotti and a copy of this report, LIC 809D and appeal rights were given at the time of inspection.