Facility Evaluation Report

On September 16, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on two incidents that occurred on 8/28/25 and 9/3/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit.

On 8/28/25, the Licensee reported that the agency nurse failed to provide Resident 1 (R1) his/her PM medications. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication. The facility failed to provide R1's medication as prescribed by the physician.

On 9/3/25, the Licensee reported that an agency CNA (S1) was attempting to assist Resident 2 (R2) with changing his/her brief and started rummaging through R2's nighstand drawer. R2 refused assistance and S1 threw R2's pajamas at R2 and told R2 to not call for assistance again. All required parties were notified, including the Belmont Police Department. Regional Sales Specialist, Jessica Wiggins ended S1's shift and immediately walked the S1 out. S1 is no longer allowed in the community.

During the visit, LPA reviewed the facility's internal investigation, attempted to interview R2, discussed the incident with the administrator, and reviewed R2's file. Based on R2's file reviewed, R2 has a diagnosis of Parkinson's Disease. Based on R2's service plan, R1 is independent and does not require assistance with toileting and dressing. According to staff interviewed, although R2 is independent, due to his/her Parkinson's disease, facility staff check in on R2 and offer assistance. Based on the facility's internal investigation, R2 was not missing any personal belongings and R2 was not injured. LPA was unable to interview R2 during the visit. A statement was provided to facility by S1 indicating, he/she was only trying to assist R2 with changing R2's pants and diaper.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $1,000.00 is issued today for a repeat violation within the last 12 months for CCR 87465(a)(4). Report is reviewed with the administrator and a copy is provided with appeal rights. A copy of civil penalty is provided.