Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and met with Hanna Peralta Administrator. The purpose of this Case Management Visit is to follow up on another agency report submitted to Community Care Licensing (CCL) regarding areas of concerns of medication management, facility repair and menu rotation.

According to the report, the centrally medication log did not include documentation for specific quantities and a spot check of medications revealed some discrepancies regarding documented amounts on hand. Also, it was observed by an outside agency that the exterior door at the end of the hallway had an unsealed gap between the top of the door and the door frame, allowing air to enter the home. During today's visit, LPA/Administrator toured the area of concern and LPA was informed that the gap issue was already fixed and the facility is in good repair. Regarding the menu rotation, The Administrator stated that the Registered Dietician is scheduled to come on 2/23/26 to revise facility menu options and sign the report that they have reviewed them. Also, Administrator explained to LPA that the discrepancy was about the amount of medication received versus the amount documented in the centrally stored medication log. For example: if certain medication comes in two different bubble packs and the label stated 60 pills, then the facility will document the medication in two different lines, but they were documenting 60 pills for each bubble pack instead of 30 pills, which were the real quantity received in each bubble pack resulting in recording client's medication inappropriately. Based on LPA's records review, the Administrator is addressing areas of concerns, the facility have conducted all staff training on 2/4/26 regarding medication documentation on centrally stored medication log. LPA observed centrally stored medication log quantity column is kept blank for staff to enter the actual quantity of pills received in one bubble pack instead of entering the quantity specified on the label of two or more bubble packs of the same medication to ensure that medication stored is recorded according to regulation.

No deficiencies cited during today's visit. Exit interview conducted with Administrator and a copy of this report was given.