Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to the department. LPA was greeted and granted entry and explained the reason for the visit.

SOC 341 submitted to the department on 06/13/2026 indicated Resident 1 (R1) had verbalized that Staff 1 (S1) had been rough with the resident. Law enforcement was called and OC Sheriff responded, case #061226-0719. The staff was immediately suspended pending an investigation and subsequently terminated. LPA observed S1 signed the "Acknowledgment to Report Elder Abuse" on 08/20/2024. LPA observed S1's current training records. Interview with R1 confirmed the incident notated on the SOC 341.

Incident report dated 07/06/2026 indicated S2 had administered metronidazole 250mg, orally to R2 instead of placing on the resident's heel as directed. S2 notified management and poison control was contacted. Resident was monitored per poison control recommendations and no adverse affects were noted. Per Silverado assessment dated 03/23/2026, R2 is diagnosed with Dementia and unable to administer own medications. Resident appraisal dated 03/21/2026 indicates R2 has wounds on the heels of both feet. R2 is on hospice care.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights was provided to the facility representative.