Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo returned unannounced to complete the required Annual inspection and was greeted by concierge. LPA met with Administrator Lauren Cottman.

On 6/9/26 LPA arrived at facility to conduct annual inspection. Today, LPA returned to complete inspection.

At approximately 10:30am LPA, Admin, and MedTech began spot check of medication. Facility uses an electronic MAR and medication management system. Signed doctors' orders were on file. Facility utilizes e-MAR for PRNs. LPA advised to MedTech to ensure both reason for administering and outcome of administration are recorded and to provide as much detail as applicable. LPA advised that doctors' ordered must be followed per written instructions.

LPA, Admin, and MedTech discussed medication documentation management and possibly incorporating an organizational system that houses all the current signed doctors' orders and discontinuation notices in one location for each resident. Admin provided LPA recent pharmacy audit documentation conducted on 2/13/26. All audit criteria shows as met or not applicable. No deficiencies cited.

LPA issued citation for deficiencies identified on 6/9/26, except one. LPA did not issue citation for deficiency of Health and Safety Code (HSC)1569.696 as Admin provided LPA documentation showing all subject matters were covered by vendor training. Therefore, facility found to be in compliance with HSC1569.69. No deficiencies identified at today's continuation visit.