Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and was greeted by staff, Evelyn Vitug. Hanna Peralta Administrator was unable to come to the facility, but was available by phone and gave authorization for staff to sign the report. The purpose of this Case Management Visit is to follow up on another agency report submitted to Community Care Licensing (CCL) regarding medication documentation error occurred on 6/1/25 and 6/14/25.

According to the report, a spot check of medications conducted on 8/27/25 revealed that a medication bubble pack for client (C1) as needed Loratadine (10mg) contained two opened and emptied pouches labeled with administration dates of 06/01/25 and 06/14/25. However, the Medication Administration Record for June 2025 indicated that administration occurred on 06/02/25 only. There was no documentation on the MAR that medication was administered on 06/01/25 or 06/14/25, and the bubble pack did not have record that medication was administered on 06/02/25. During today's visit, LPA/Administrator discussed via phone the importance of recording dosage of client's medication accordingly. Based on records review, the Administrator conducted all staff training on 8/31/25 regarding medication administration record, since several staff were involved in the documentation error. Also, staff have reviewed the medication logs and documented a late entry of PRN medication.