Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to address deficiencies observed during today's complaint visit. LPA met with Administrator, Jasmine Latu and stated the purpose of the visit .

During today's visit, LPA Rai observed 3 resident rooms (R1-R3) with Health and Wellness Director (HWD) Ann Lee. At 1:03pm, LPA Rai and HWD entered R1's room and observed centrally stored medications and over the counter medications on the kitchenette counter and cabinet below. HWD stated she was not aware of the medications R1 kept in the cabinet. R1 showed medications placed in a 7-day medication storage. Based on review of R1's Physician's Report dated 5/19/2025, R1 cannot administer and store own medication. HWD confirmed R1 does not have physician's order on file to allow R1 to administer or store own medication and facility staff did not assess resident to ensure residents’ safety would not be at risk if allowed access to store own medications.

At 1:10pm, LPA Rai and HWD entered R2's room and observed expired prescription topical cream on a bookshelf near the room's entrance. LPA Rai observed PRN medication on another bookshelf near the room's entrance. LPA Rai observed laundry/cleaning solution on the floor near the room's entrance. HWD stated the facilty staff assist with administer resident's medication and R2 should not have access to medication. HWD immediately removed the expired medication and PRN medication. HWD stated Hospice agency aide and family assist with R2's laundry therefore they use the laundry/cleaning solution which is located in the room. HWD stated the laundry/cleaning solution will be kept inaccessible to resident in the resident's room. Based on review R2's LIC 602A Physician's Report dated 6/19/2023, R2 is not able to administer or store own medications.