Facility Evaluation Report

Licensing Program Analyst (LPA) Melisa Rankin along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana conducted an unannounced complaint visit which prompted a Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control # 29-AS-20251218100949. LPA met with Administrator Pamela Holcombe and explained the reason for the visit.

During the investigation, LPA and QAS toured the facility and checked medication cabinet and found it to be unlocked. LPA photographed the medication cabinet drawer they were able to open, which poses a risk to the health and safety of residents as medications must be kept inaccessible to unauthorized individuals.

LPA also toured the facility to review previously discussed areas of concern. In Bathroom 2, LPA observed toilet paper under the bathroom cabinet that had been chewed by a rodent, along with what appeared to be mice droppings inside the cabinet. This issue had been previously discussed during an annual visit, and a prior image was taken at that time. Additionally, LPA observed that the bathroom door and light switch had a reddish-brown colored substance. These same areas were noted during the annual visit, and documented with images; however, the same substances were still present and were compared to prior images. The smudges were the same and in the same location.

Based on current observations and prior documentation, the facility is being cited for deficiencies related to cleanliness and sanitation and safeguarding of medications. These conditions pose potential health and safety risks to residents and indicate that corrective measures previously discussed were not adequately implemented.

Copy of report printed, appeal rights discussed.