Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Sanjay Kabadi, Administrator was unavailable but greeted LPA later.

On 7/17/25 LPA issued citations for deficiencies of regulations: Health and Safety Code (HSC)1569.269(a)(6), CCR 87465(h)(5), and CCR 87465(a)(4). The plan of correction for HSC1569.269(a)(6) required facility to submit plan to CCL to conduct personal rights training and training for all direct care staff on prompt call/pendant response times by plan of correction due date. Training to be conducted through facility's chosen vendor, Relias as well as an in-service training by no later than 8/7/25. The plans of correction for deficiencies of CCR 87465(h)(5) and 87465(a)(4) required facility to submit plan to conduct in-service training on pre-pouring medication and medication administration training by plan of correction due date. In-service training to be conducted no later than 8/7/25. Additionally, facility to submit written procedure plan to conduct daily audit of medication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 8/7/25.

On 7/18/25, Health Services Assistant (HSA) Pam Brown submitted required plans for these deficiencies. However, as of today, CCL has not received the in-service training logs nor the Relias training records required for the plan of correction. So, these deficiencies are being re-cited today ( deficiencies cited, see 809D ).

During visit, LPA found medication room unattended, unlocked, and with medication bubble pack accessible to residents ( deficiency cited, see 809D ).