Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Diane De Guzman, Administrator.

The purpose of the visit was to follow up on an incident self-reported by the facility to the department via Unusual Injury/Incident Report (IR) on 03/22/2025. The incident occurred on 03/22/2025 and involved resident R1's bottle of medication M1 being reported as missing. The IR states that staff S1 was assisting R1 in the administration of R1's bottle of M1 around 10:00 AM. After completing medication rounds to residents in the facility, S1 left R1's bottle of M1 on top of the medication cart without securing the bottle of M1 inside the locked storage of the medication cart inside the medication room. S1 then proceeded to leave for S1's lunch break and does not recall if S1 locked the door to the medication room. At 2:00 PM, S1 was working with another medication technician to prepare the evening medications when both staff noticed that R1's bottle of M1 had gone missing. After searching the facility, S1 was unable to locate R1's bottle of M1 and notified the facility Administrator and Director of Staff Development. Law enforcement was notified and a police report was made.

During visit, LPA Marrufo obtained a copy of the facility medication storage policy, R1's Admission Record, the Controlled Substance Accountability Sheet that was used for R1's bottle of M1 on the day it went missing, and Staff Schedule.

See LIC809-C page for more information. Page 1 of 2.