Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced at this facility to open a complaint investigation pertaining to complaint 21-AS-20250307140033. LPA met with Administrator Domonique Thomas.

During investigation, Admin advised LPA that resident (R1) has been picking up their own prescriptions from the pharmacy and that the Admin did not know where R1's prescription for Buspirone 5mg was as a result. LPA observed medication to be listed on the Centrally Stored Medication log but not present in the medication drawer for R1. LPA reviewed R1's physician report which states that they cannot administer or store their own medication. Additionally, Admin advised that R1 has not been taking their medication but could not produce refusal documentation that was complete and current. LPA advised that for residents that cannot administer or store their own medication that she is responsible for every aspect of administering and storing the medication (deficiency cited, see 809D)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given .