Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit to deliver findings from a completed Case Management investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Nick Fierro.

The Department previously conducted a separate Complaint investigation regarding neglect and lack of supervision and medication errors, concluding that case was Substantiated. With the current Case Management case, CCLD investigated the incidents of (1) failure to seek timely medical attention after C1's first suicide attempt, (2) staff falsifying medication logs due to medication errors and (3) staff not conducting a pre appraisal prior to Client 1 (C1) being placed at the facility. [See LIC 811 Confidential Names List for a description of select person and staff identifiers used.]

Records and interviews showed: On 12/08/2025, LPA Rogers received documents from the facility regarding C1. LPA observed there wasn't a resident appraisal completed by facility staff for review.

Records and interviews showed: Staff members admitted to not providing C1 with their medication for two weeks. Interviews revealed the medication records were falsely initialed verifying that the medications were given. Interviews revealed the staff members stated they initialed the records but did not provide the medications to the client.