Facility Evaluation Report

At approximately 08:50AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to conduct a Case Management – Deficiencies visit and met with Licensee, April Thomas.

During the course of the Complaint Investigation received on 05/16/2025, LPAs observed the following deficiencies: During visit conducted on 05/20/2025, LPAs observed the following:

•12 pre-poured tablets of Oxycodone located in a plastic cup.

• Facility was not documenting their centrally stored medication in its entirety or storing the narcotic medication safely. Per discussion with Licensee, narcotics were being held in their personal room instead the facility's designated area for centrally stored medications.

During visit conducted on 07/23/2025, LPAs made the following medication observations:

• AM, PM, and Evening medication were pre-poured for residents located in one of the facility’s kitchen cabinets. Per Licensee, the identified medications were poured approximately a week prior to LPAs conducting their visit. LPAs observed that the plastic cups were not labelled to identify the appropriate resident. Per Licensee, they pass the medication daily and therefore know on sight which medication is supposed to be given to each resident.

• Multiple weekly medication trays located in the facility’s medication closet with pre-poured medication.

• LPAs did not observe a properly documented centrally stored medication log per regulation.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.