Facility Evaluation Report

At approximately 9:35PM, Licensing Program Analysts (LPAs) Felias and Contreras arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Josephine Kamau.The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL).

Incident Report 1 : On 4/07/25 CCL received an incident report. Per report, on 4/06/2025, a medication audit was completed and discovered that Resident 1 (R1) morning medication was not administered on 4/04/25 and 4/05/25. Report stated that facility monitored R1 for adverse effects. R1 was found to be in good health. Facility made all appropriate notifications per regulation.

Per discussion with Administrator, Staff Member 1 (S1) received additional medication administration training. Copy of training obtained during visit.

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.

** Deficiency cited today, 04/15/2025, has been cleared during visit. Plan of Corrections Letter provided.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.