Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit.

On August 7, 2025, the Department received an incident report regarding a medication error for R1. The incident report revealed that on August 7, 2025, it was discovered by Regional Director of Health and Wellness that R1 has missed all his medications for more than 30 days since R1 does not have an active primary care physician to prescribe refills.

LPA and Regional Director of Health and Wellness discussed over the phone that the medication error was brought to the community's attention but it was not addressed until Regional Director of Health and Wellness was informed. Regional Director of Health and Wellness informed LPA that it has since been resolved, R1 now has a primary care physician who has since prescribed refills for medications.

As a result of today's visit, deficiencies cited. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.