Lorie's RCFE LLC #3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 8:40 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Claire Aviado, administrator designee and Freda Robles the Administrator and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 5 resident bedrooms, 1 staff bedroom, and 3 bathrooms currently occupying 5 residents. The facility has smoke and carbon monoxide detectors that were tested and working at the time of visit. The lighting is sufficient for the use of the facility and resident comfort. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid mats/flooring. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. Operational Requirements: The facility has current liability insurance that expires on 9/11/26. The facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 2 bedridden residents. A hospice waiver is approved for 2 residents. Continued 809-C Personnel Records & Training: The facility employs 10 caregivers who work full-time and/or as relief as needed, and 3 administrators. Five files were reviewed for, but not limited to current 1st Aid/CPR, Health screening with TB results, Criminal Record statements, files were complete. The Administrator Certificate expires 3/9/2027. Staff have annual training completed for various required subjects/topics and hours for 2026. Resident Records & Incident Reports: The facility keeps resident records confidential. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for, but not limited do, current Physician Records and Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept complete. Food Service: The kitchen and storage areas were clean and maintained. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly drills, the last disaster drill was conducted on 6/9/2026. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The fire extinguishers were last charged and inspected on 4/20/26. The facility has a sprinkler system throughout. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit gate alarms are working. Exit door alarm to room next to the front door will be replaced as it leads directly to the outside and the alarm was faint. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility mishandling client's medication Facility failed to notify Licensing agency of eviction.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Back-up Administrator Claire Aviado and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 6/6/2025, where LPA conducted an interview with the administrator, licensee, and back-up administrator and obtained relevant documents. Additional interviews were conducted with relevant parties on 6/4/25, 6/5/25, 6/6/25, 9/23/25, and 10/1/25. Additional documents were collected during collateral visit on 8/19/25. On the allegation: Facility mishandling client's medication It was alleged that the facility did not properly supervise, record, distribute, and manage medication for R1. Continued on 9099-C Substantiated RP states that carbidopa levodopa was often not on time as directed by doctor. Interviews with two witnesses state R1 had expressed concern that the Parkinson’s medication carbidopa levodopa was not given as ordered. Interview with witnesses, F1, and administrators all state medication orders for Parkinson’s would change “all the time.” LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Records (MAR), these records along with Physician Visits notes showed orders for Carbidopa changed at least 4 times since November of 2024. A CSMDR medication note is written in that an order for 2 tabs by mouth 6 times a day started on 10/21/24 by Physician #1. 11/2/24 2 tablets 3 times a day by Physician #1. 12/3/24 2 tabs by mouth 6 times a day by Physician #1. Physician Visit notes by Physician #2 on 3/21/25 stated to “remove the extra 2 carbidopa…” then lists 5 different times to distribute. Then another change by Physician #2 of this medication on 4/21/25 back to 6 times a day. LPA reviewed the CSMDR and found that the 2 orders noted on the Physician Visit notes were not updated on the CSMDR records and the MAR due to Physician #2 is not the prescribing physician and the prescribing physician #1 would be upset with the attempt to override their orders. Additionally, the CSMDR has a record that a prescription from Physician #1 with the same prescription number as the October through March orders was started on 4/5/25 and is the only Carbidopa medication listed on the CSMDR which kept the order of 2 tabs by mouth 6 times a day. Physician Visit documented on 5/8/25, notes from Physician #3 state R1 was swollen and there was to be an increase in Furosemide. Physician visit note shows Physician #4 on 5/16/25 noted “lasix 40 mg daily”. Furosemide and Lasix are the same medication. The new medication was not filled until 5/16/25 and was not started per the CSMDR until 5/21/25. Per documentation, this is a delay in following doctor’s order for at minimum 12 days and 5 days following receipt of the medication. Continued on 9099C Discussion and review of Facilities Physician Visit notes show that Credible Witness 2 (W2) states on 3/18/25 that resident was observed breathing heavily during a visit. 12/17/24 notes from W2 state R1 was “concerned about medication management by staff. Reporting multiple people giving (R1) medications at inconsistent times.” Interview and record review from staff at facility where R1 transferred on 5/29/25, a copy of the medication release form was provided to LPA. This form lists all medication that came from Lorie’s RCFE and signed off by the responsible party. The form has written quantities appearing to be from Lorie’s staff with 8 of the 18 medications listed having adjusted quantities written in with a plus sign and an added number. Staff at the new facility stated that the medication was counted upon intake and an adjustment to one of the medication counts was noted on their copy of the form. There were four medications noted by Lorie’s RCFE to have a quantity ranging from 165 to 772 pills being sent to the new facility. Administrators claim that family would request leftover medication to be kept due to co-payment needed for each change. LPA review of CSMDR shows the facility would start medications out of date fill order, one instance a medication started in 4/20/25 was filled in 8/7/24, another instance started 4/6/25, was originally filled 10/11/24. It is also noted that RX numbers were opened out of order, even when no change in doctor order is noted. Of the 7 medications reviewed, there are 12 instances where the medication is not listed on the CSMDR record for multiple months, but the MAR provided record that the medication was given during these months. Based on interviews and record reviews, the allegation is Substantiated. The facility failed to maintain accurate and consistent medication records,and based on records delayed implementation of physician orders. Continue 9099-C On the allegation: Facility failed to notify Licensing agency of eviction. LPA discussed with Licensee regarding the requirement to provide Licensing with a copy of eviction notices. Licensee stated they were unaware and would provide a copy of the notice. Notice was emailed to Licensing on 6/6/25. Notice given to R1 was dated 5/1/25 and had an eviction date of 5/30/25. Resident moved out on 5/29/25. Based on the interview and record review, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. On the allegation: Staff failed to meet resident's medical needs It was alleged the facility failed to meet R1’s medical needs, including concerns related to wound care, incontinence care, use of an inhaler, response to call bells, and feeding assistance. LPA reviewed the facility’s Home Health Documentation Log and interviewed a Home Health agent (W1). Records show that a Registered Nurse (RN) and Licensed Vocational Nurse (LVN) provided wound care and medical oversight on 4/25/25, 4/28/25, 5/1/25, 5/5/25, 5/9/25, 5/12/25, 5/16/25, 5/19/25, 5/21/25, 5/26/25, and 5/29/25. W1 confirmed that nurses’ notes documented wound care, fall prevention education, and management of bilateral edema. W1 stated that no concerns were noted regarding facility staff or care, and staff were described as attentive and caring. Interviews with home health staff confirmed instructions provided to staff were followed regarding wound care. Records reviewed also showed that Speech, and Physical Therapy had visited the resident eight times from 4/25/25 to 5/29/25. Interviews with staff and administrators from both this facility and a subsequent facility where R1 resided confirmed that R1 was able to advocate for their needs. Staff reported that R1 did not always inform them when their brief was wet. One incident was noted where R1 was observed with wet pants, and staff stated R1 had been changed earlier but had not communicated the need for another change. Interview with F1 stated Administrator Claire instructed staff to increase the frequency of checks for R1’s incontinence needs. It was alleged that staff initially used medical tape to treat a skin tear from a fall. F1 stated that Administrator Claire later re-dressed the wound using steri-strips and believed the initial use of medical tape was inappropriate. However, there was no documentation from Home Health or other medical professionals indicating that the use of medical tape caused harm or was improper. It was alleged that R1 was being fed too quickly. F1 stated that Administrator Freda reportedly instructed staff to slow down during feeding. An Occupational Therapist (OT) was brought in to support R1’s independence with feeding. OT notes reviewed with W1 indicated that both staff and R1 demonstrated understanding of feeding instructions. Follow-up visits on 5/13/25 recommended adaptive utensils and plates, with improvement noted. The final OT note on 5/27/25 stated that the goal of independent feeding was “not attained” and that R1 would continue to require assistance. It was alleged staff did not respond to R1’s call bell for their inhaler. Interview with F1 stated while on the phone with R1, R1 needed their inhaler and was told to ring their bell. R1 stated no one responded, so F1 text an administrator to get the inhaler. Per F1, staff were “annoyed” and said R1 would ask F1 for care that was needed, including the inhaler, but did not ask staff for it. Text messages showed multiple occasions where R1 communicated needs to F1, but not to facility staff. Interview with witnesses stated that R1 was hallucinating at night, having night terrors, and increased anxiety. R1 claimed the anxiety was due to no one responding to their calls at night. It was noted on a physician visit on 3/18/25 that R1 was “concerned about breathing – heaviness at night mostly. [R1] is also having increased anxiety due to staff not responding to [R1] call/bell ringing at night.” Per W2 notes, R1 still reported night terrors on 4/8/25. An incident report states on 2/15/25, R1 made a call to 911 claiming another resident was having a heart attack. Emergency personnel showed up and checked on the other resident, and found other resident was asleep and not experiencing any issues. Another incident report on 3/13/25 noted that at 11:10pm during rounds, staff noticed resident was awake, hallucinating, had made a mess of R1’s room and also admitted to calling the facility house phone. The administrator and F1 were notified of this behavior. On this same report, facility states that family instructed staff to take R1’s cell phone at night, and it was stated by family and administrator that R1 was aware and ok with this. Interviews with staff stated they always respond to bells during the day and night, have awake staff at night. LPA verified the bells used was at one time a hand bell and at one time a push button remote bell, both were audible throughout the house. LPA unable to conduct interview with current residents in care due to cognitive concerns. A physician’s report dated 5/15/25 stated that R1 required a higher level of care, specifically Skilled Nursing. The facility issued an eviction notice based on this assessment. Administrators and documentation confirmed that R1 was declining, had increased fall risk, and was resistant to staff education and redirection. A Home Health RN note described R1 as “resistant to education.” The investigation showed the facility attempted to meet R1’s medical care needs, and no concerns were noted in documentation or interviews from medical professionals who treated R1 at the facility. Although the allegation may have occurred or is valid, there is insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit report provided to administrator.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 29-AS-20250604185454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Oct 15, 2025

87224(f) Eviction Procedures A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when an eviction notice was not sent to licensing, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Licensee agree to review reporting requirements for RCFE's in various sections of Title 22 and provide a statement acknowledging review of and training to administrators of these requirements 87224 - Eviction Procedures, 87705, 87211 - Reporting Requirements.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 15, 2025

87465(a)(4) Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as 6 of 7 resident medications reviewed contained inconsistencies with their medication quantity and amounts documented as administered on the MAR which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by POC due date 10/15/25.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control # 29-AS-20250604185454. LPA met with Back-up Administrator Claire Aviado and explained the reason for the visit. During the complaint investigation LPA did a review of medication records for residents currently residing at the facility, the following deficiency was observed: An audit of the Centrally Stored Medication and Destruction Records (CSMDR) and Medication Administration Records (MAR) LPA noted 11 medications refills were not logged as required. It was observed that there was three months’ extra supply of medications on hand that had not been recorded. Additionally, an audit of the medications showed missing CSMDR logs for January medications. Further review showed that the medication refills were not used in order of the supply on hand, the records stated that refills used in August were July refill and September was August refill, but LPA found that the July and August refills were still pending use and the records were inaccurately recorded. In one case the prescription stated one tablet by mouth twice a day, but facility had reduced the medication to one time a day due to the medication side effect on the resident but had not obtained a discontinue or updated doctor’s order to support the change. Continued on 809-C Based on record review for resident 1 (R1) and additional review of records for resident 2 (R2) the facility is being cited for inaccurate record keeping and failure to note all medications on the CSMDR. Facility was reminded Physician orders should be followed and updated if changes are required, facility was reminded that medication should be used in the order it is received, unless a order has changed, that all medications, once received at the facility should be recorded on the CSMDR, that the information on the CSMDR needs to be accurate and match the medication packages, and that the administrator should do training any time an error occurs, as well as the required annual 16 hour training and that medication audits should be done regularly to ensure staff are following all requirements for the safety of residents in care. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Oct 15, 2025

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications...is maintained... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as 11 refill medications were not logged, medications logged was logged in with incorrect refill dates and discontinued orders were not on hand for medication that was reduced which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Administrator agreed to complete a medication audit and to log all medications properly on their respective CSMDR. Administrator will submit proof to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 10:45 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Claire Aviado, administrator designee and Freda Robles Administrator explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 5 bedrooms and 3 bathrooms currently occupying 4 residents. The facility has smoke and carbon monoxide detectors that were tested and working at the time of visit. The lighting is sufficient for the use of the facility and resident comfort. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid mats/flooring. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. Operational Requirements: The facility has current liability insurance that expires on 9/11/25. The facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 2 bedridden residents. A hospice waiver is approved for 2 residents. Personnel Records & Training: The facility currently employs 5 full-time caregivers, and 3 administrators. Records are kept confidential. Files were reviewed for, but not limited to current 1st Aid/CPR, Health screening with TB results, Criminal Record statements, files were complete. Continued 809-C The administrator file was reviewed for Continuing Education requirements and Designee Administrator Certificate expires 9/2026. Staff have annual training completed for various required subjects/topics and hours for 2025. Resident Records & Incident Reports: The facility keeps resident records confidential. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for, but not limited do, current Physician Records and Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept complete. Food Service: The kitchen and storage areas were clean and maintained. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Additional medication processes are being implemented. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducted a quarterly disaster drill 6/12/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The fire extinguishers were last charged and inspected on 4/23/25. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit gate alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 8, 2025

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Miller arrived at 9:15 a.m and made an unannounced 1-year required annual visit to the facility above. LPA met with Claire Aviado, administrator and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap. The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on 2/5/24. The facility has 5 resident bedrooms, 1 staff bedroom and 3 bathrooms currently occupying 4 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and are locked in a shed in the backyard and in a cupboard in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance that expires on 9/11/24. The facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 4 non- ambulatory and 2 bedridden residents. A hospice waiver is approved for 2 residents. The facility currently has 4 non-Ambulatory, 2 of which are on hospice. Staffing: The facility currently employs 5 full time caregivers, and 3 administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and Administrator Certificate expires 8/14/25. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept confidential. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Continued 809-C Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill 7/4/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 14, 2024