Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPA met with Executive Director (ED), Margie Veis and the reason for the visit was explained. The LPA focused today’s visit on ensuring the Medications and Centrally Stored Medications and Destruction Records (CSMDR) are in order and in compliance with Title 22 Regulations.

During today’s visit, the LPA conducted a medications review in assisted living starting at 09:50 a.m. and memory care starting at 10:40 a.m. A total of five (5) randomly selected residents’ medications and CSMDR were reviewed, and the following was noted:

During the medication review, it was revealed that 3 out of 5 residents have routine medications that were started but are not documented on the CSMDR. Additionally, 2 out of 5 residents have medications missing start dates on both the CSMDR and the corresponding start date sticker on medication, preventing the LPA from verifying whether the medications are being administered as prescribed. The review also revealed that Resident #1 (R1) is prescribed bedtime medications—Melatonin 3 mg tablet, one tablet at bedtime as needed, and Carbamazepine 200 mg, half a tablet twice daily—both with a documented start date of 07/05/2025. However, each medication is missing one dosage, and there are no documented notes indicating that staff have observed the missing doses.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided.