Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with Complaint #22-AS-20240711133659. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA toured the facility and reviewed medications as well as reviewed file for Resident 1 (R1). Audit of three of R1's medications showed that medications on hand do not match start date of medication bottles and Medication Administration Record is missing multiple staff initials for May, June and July 2024. Information obtained during complaint investigation indicated R1 had a half bed rail during the time of complaint incident. Facility does not have an order for half bed rails in resident file.

Based on the visit conducted, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.