Facility Evaluation Report

On 6/25/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management deficiencies inspection to address deficiencies observed during a complaint investigation.

LPA requested the file and medication administration records (MARs) for former Resident R1 (See confidential names list, LIC 811 dated 6/25/25) LPA was provided the file for former resident but the facility did not retain the MARs for R1 after leaving the facility. Per California Code of Regulations, Title 22 facilities are required to retain resident records for three years after the termination of services. LPA was unable to review files and staff present states they do not have the files requested.

Additionally, LPA observed that the facility is administering medications to R2 without a physician's order. LPA observed the facility has been administering over the counter Claritin for several months without a physician's order. additionally, the facility has been administering the Claritin two times daily which in excess of the recommended dose not to exceed one pill in 24 hours. LPA has also observed the facility has not been following the physician's order for daily blood glucose monitoring.

Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. An immediate civil penalty was also issued during today's inspection.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.