Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – deficiencies visit. LPA met with Administrator, Audrey Ann Salvador.

During a complaint investigation for control number: 26-AS-20240920103156, a violation was found. In the investigation, it was found that a resident (R1) was not administered medication prescribed by the doctor after the resident was discharged back to the facility on 09/12/2024. Based on review of R1’s medical discharge paperwork, it shows that the doctor had prescribed R1 medication which was to start on 09/13/2024. The review of R1’s centrally stored medication record and medication administration record did not include the new prescription.

Based on staff interviews, it was stated that when R1 returned from the hospital the night of 09/12/2024, R1’s responsible party handed staff the discharge paperwork and sent a picture of the paperwork to the Administrator who was out of country. It was stated that the facility was informed that R1 was prescribed new medication when R1’s responsible party visited the facility on 09/14/2025 and questioned if R1 was administered the new prescription. It was stated that the staff did not follow-up with the pharmacy timely regarding R1’s medication and did not start the medication on 09/13/2024 per physician's order.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Audrey Ann Salvador and a copy of the report and appeal rights were provided.