Residential First Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit today at 10:00 a.m. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by facility staff, Jackie Olivera and the reason for the visit was explained. Caregiver contacted the Administrator by phone, Lidia Medina. At 10:50 a.m. Administrator arrived at the facility. Entrance interview conducted. Starting at 10:55 a.m., the LPA along with the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. This facility doesn’t have a staff room; facility will provide 24/7 care. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a service date of 03/15/2025. Required postings were observed throughout the common space. Continued on LIC 809-C Continued from LIC 809 The LPA observed a fireplace adequately covered at the time of the visit. Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed additional clean linens and towels for resident use. Auditory alarms were observed at the time of the visit. Hardwired combination smoke and carbon monoxide detectors were tested at 11:05 A.M. and were functional at the time of the visit. BATHROOMS: There are two (2) bathrooms designated for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Beginning at 11:00 a.m., LPA measured the hot water temperature in both bathrooms. The hot water temperature in the shared bathroom measured 108.7. The hot water temperature in the master bedroom measured below the required regulatory standard. Per the Administrator, an individual water heater was recently installed, and staff are in the process of adjusting the temperature to meet regulatory requirements. Technical assistance (TA) issued. KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:13 a.m., the hot water temperature was measured in the kitchen sink, and it measured at 108.6 degrees Fahrenheit. GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care. BACKYARD: The backyard has a covered patio area with patio furniture for residents’ use. All passageways were observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. LPA observed a locked shed where mobility devices are stored. Continued from LIC 809-C RECORDS: Beginning at 11:45 a.m., LPA reviewed Resident Records. and Personnel Records. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. LPA observed that three (3) out of four (4) residents did not have a current Needs and Services Plan on file. Three (3) personnel and current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. Current Administrator’s Certificate is valid until 05/21/2026. MEDICATIONS: Medications review began at approximately 1:50 p.m. The medications are locked in a cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 12/02/2025. During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A). A copy of the facility's liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today at 10:30 a.m. Upon arrival, there were two (2) staff and five (5) residents present. The LPA was greeted by facility staff, Eloisa Vasallo and the reason for the visit was explained. The Administrator is currently unavailable but has designated staff to sign report. Entrance interview conducted. Starting at 10:31 a.m., the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at 10:31 a.m. Knives and sharps were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:33 a.m., the hot water temperature was measured in the kitchen sink, and it measured at 118.6 degrees Fahrenheit. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 03/15/2024. Required postings were observed throughout the common space. The LPA observed a fireplace adequately covered at the time of the visit. Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed additional clean linens and towels for resident use. Auditory alarms were observed at the time of the visit. Report Continued on LIC 809... Report Continued from LIC 809... RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:40 a.m., the hot water temperature was measured in both bathroom and they measured between 105 and 120 degrees Fahrenheit. BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). BACKYARD: The backyard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. RECORDS: LPA reviewed Resident Records at 11:00 a.m. and Personnel Records at 11:57 a.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All files were in order. Four (4) personnel and current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. Current Administrator’s Certificate is valid until 05/21/2026. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 10/01/2024. MEDICATIONS: Medications review began at approximately 12:50 p.m. The medications are locked in a cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Neglect/Lack of Supervision: Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining a fracture from a fall while in care. Facility staff are not providing adequate supervision to residents in care. Facility staff left resident in a soiled diaper for a long period of time.

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPAs met with Administrator, Lidia Medina, and explained the reason for the visit. On 07/28/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that the facility staff failed to provide supervision to Resident #1 (R1) resulting in R1 falling and sustaining a hip fracture. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Heidy Bendana. (Report Continued on LIC 9099C...) Substantiated (Report Continued from LIC 9099...) On 07/29/2023, LPA Martha Arroyo conducted an initial 10-day complaint visit. During the visit, at 8:30 a.m., LPA conducted a physical plant tour to ensure there were no health and safety concerns. Between 8:04 a.m. and 10:03 a.m., the LPA conducted interviews with the administrator, one staff member, and three residents. At 8:55 a.m., the LPA conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. LPA Arroyo also conducted one staff interview on 08/15/2023 at 3:13 p.m. and telephonic interviews with family members on 11/30/2023 at 10:13 a.m. and 10:55 a.m. Investigator Bendana conducted interviews on 08/25/2023, at approximately 2:12 p.m., with R1’s resident representative; on 08/28/2023, at approximately 10:24 a.m., with the reporting party; on 09/12/2023, from approximately 11:02 a.m. to 11:35 a.m., with Staff #1 (S1), Staff #2 (S2) and residents; on 09/21/2023, at approximately 9:42 a.m., with the administrator; and at 10:28 a.m. attempted to interview R1, however, R1 declined to be interviewed. In addition, the investigator reviewed Adventist Health Simi Valley Hospital medical records and facility file documents related to R1. A review of R1’s Physician Report, dated 06/13/2023, lists R1’s primary diagnosis as dementia. The secondary diagnosis is listed as osteoporosis, macular degeneration. The report noted R1 has a visual impairment, uses a walker and is a fall risk. The Preplacement Appraisal Information, dated 6/28/2023, indicates R1 is not able to walk without any physical assistance, is feeble or slow, uses a walker, is unsteady and needs assistance with all activities, even basic activities. R1 is at risk for falls, needs help transferring in and out of bed and dressing; needs help with bathing, hair care and personal hygiene; needs help with moving about the facility; needs assistance with toileting including equipment assistance or assistance of another person; and R1 needs special observation/night supervision due to confusion, forgetfulness and wandering. A review of R1’s hospital medical records revealed R1 was admitted to Adventist Health Simi Valley Hospital on 07/22/2023, with the chief complaint of an unwitnessed fall, and left femur deformity. R1 was found to have a femur (hip) fracture and orthopedics were consulted. R1 had surgery to the left femoral shaft fracture intramedullary nailing. R1 was discharged to a Skilled Nursing Facility (SNF) on 07/27/2023 for rehabilitation. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) The investigation revealed the statements made by the overnight staff (S1) and the administrator were inconsistent. The administrator stated on 07/22/2023, S1 made rounds at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m.; however, staff interviews reflected that they could not recall how often rounds were made. Additionally, it was revealed that night rounds are done frequently but there is no set time for rounds. Moreover, interviews revealed that R1 fell at night and was found in the morning by S1. The administrator and S1 stated R1 used a bell to call for assistance, however, there was no evidence of a bell or call button found. Interviews conducted with other parties reflected that residents are checked on often during the day but not so much at night because caregivers slept and there was a lack of supervision at night. It was revealed that caregivers check on residents if it woke them up. R1’s resident representative was informed R1 was checked on between 3:00 a.m. and 4:00 a.m. Per the unusual incident/injury report (SIR) submitted to the department on 07/28/2023, S1 was starting their day at around 6:40 a.m., was checking on the residents and found R1 lying on the floor; no one heard or saw the fall. Interviews also reflected that R1 has a commode in R1’s room, which was noted to be wet. Due to the totality of circumstances, it is more likely than not that R1 sustained an unwitnessed fall while staff slept. Staff failed to provide care according to the preplacement appraisal. The Department’s investigation provided sufficient evidence to substantiate that the facility staff slept and failed to supervise R1 resulting in an unwitnessed fall. Therefore, the allegation “Neglect/Lack of Supervision: Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining a fracture from a fall while in care” is deemed Substantiated at this time. (Report Continued from LIC 9099C...) (Report Continued from LIC 9099C...) It was also alleged that facility staff are not providing adequate supervision to residents in care and facility staff left resident in a soiled diaper for a long period of time. It was reported that facility staff is not providing proper supervision at night and that resident is often soiled when family arrives to the facility. During staff interviews, staff reported changing the residents at least every two (2) hours unless the resident requests to be changed before then. However, staff admitted to sleeping through the night and getting up to check on the residents only while they used the restroom themselves. Additionally, staff added that they check on the residents approximately two (2) times at night and at this time is when they see if the residents need anything. Interviews conducted with family members revealed that upon admission to the facility, they were informed that the facility felt residents required minimal supervision at night since they were sleeping and added that staff ‘did rounds here and there just to make sure they were okay’. Additionally, family stated the residents were clean in the evenings while they visited; however, they were unsure if the resident’s diapers were being changed during the night. Furthermore, nighttime supervision consist between 7 p.m. and 7 a.m. which is a twelve-hour span and staff were doing night checks approximately twice a night, indicating residents are not being provided adequate supervision and are being left in soiled diapers for a long period of time. Based on all the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegations of “facility staff are not providing adequate supervision to residents in care” and” facility staff left resident in a soiled diaper for a long period of time”. Therefore, these allegations are being Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator, Lidia Medina, was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 29-AS-20230728084857

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Jan 19, 2024

87464(d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff failed to supervise R1 resulting in R1 sustaining a hip fracture from a fall while in care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: Licensee will submit plan how you will ensure residents will be supervised based on their individual needs. Submit to CCL by 01/22/2024. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 22, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as residents are being checked approximately twice per night indicating residents are being left in soiled diapers for a long period of time, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: The Licensee has agreed to review Regulation 87468.2 and submit a statement of understanding to CCL no later than 01/22/2024.

Allegation investigated: Facility staff failed to assist resident with medication.

Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/15/2023 by LPA M. Arroyo. During today's visit, LPAs met with Administrator, Lidia Medina and the reason for the visit was explained. Entrance interview. During the initial visit on 08/15/2023, LPA Arroyo conducted interviews with the Administrator and two staff between 2:50 p.m. and 3:24 p.m., conducted a resident file review at 3:35 p.m., and obtained copies of pertinent documents relevant to the investigation. Telephonic interviews were also conducted with family members on 08/25/2023 at 2:12 p.m. and 08/28/2023 at 10:24 a.m. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099..) It was alleged that facility staff failed to assist resident with medication. It was reported that facility staff left at night and medication was inaccessible to residents until the morning. Interviews conducted with staff revealed that the facility had two (2) empty resident bedrooms and one (1) of those bedrooms was being used by the care staff at night. Staff stated the night medication that is scheduled before bedtime is usually given to the residents between 8pm – 9pm right before the resident’s usual time before falling asleep. Additionally, interviews conducted and records review revealed that all facility staff have completed the necessary training for medication including assisting residents with the administration of self- administered medication. Furthermore, staff are scheduled 24 hours each day and if needed, staff are available on premises at any time during the day or night. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff failed to assist resident with medication”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued. (Report Continued from LIC 9099...) It was alleged that facility staff are not providing adequate night supervision. It was reported that facility staff are not available between 7pm to 7am and when a resident had an unwitnessed fall in the middle of the night, the facility staff did not find the resident until the following morning. Review of documents revealed that facility was licensed without a designated staff room; therefore, the facility was required to have 24-hour wake staff on premises. Additionally, facility staff schedule revealed that facility has one (1) staff member scheduled to stay awake all night and cover between 7pm to 7am. Interviews conducted with staff revealed that there is no designated staff room on premises; however, the staff is currently sleeping in a vacant resident bedroom. During the interviews, Staff #1 (S1) admitted to sleeping throughout the night and only waking up a couple times to use the restroom themselves. At this time, S1 stated they check on the residents. Although facility staff is on premises for 24 hours, staff was asleep for the majority of the nighttime rather than staying awake and supervising the residents. Furthermore, due to staff sleeping throughout the night, adequate night supervision was not being provided to residents. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “facility staff are not providing adequate night supervision”. Therefore, this allegation is deemed Substantiated at this time. Although the allegation of “facility staff are not providing adequate night supervision” was Substantiated, it has already been cited on a separate CC#29-AS-20230728084857 today 01/19/2024. It was also alleged that licensee is not following the admissions agreement. It was reported that the facility recently updated the admissions agreement with a different rate and back dated the admissions agreement. Information obtained during the course of the investigation revealed that Resident #1 (R1) was admitted to the facility on 05/22/2023. Per R1’s admissions agreement dated 05/23/2023, it states on page 15 section D following a resident’s death that “a refund of any fees paid in advance…shall be issued to the entity contractually responsible for the fees…within 15 days after the personal property is removed”. However, on R1’s admissions agreement on page 5 under Rate for Basic Services, extra verbiage was added after the admissions agreement had been originally signed by R1’s Power of Attorney (POA) on 05/23/2023 that stated “6800 for 2 months, if R1 passed within this period there is no refund” which had a date of 06/12/2023. Furthermore, similar verbiage was added on page 6 that stated “Basic Rate 6800 for the first 2 months. No refund back”. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “licensee is not following the admissions agreement”. Therefore, this allegation is deemed Substantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 29-AS-20230808151455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 22, 2024

87507 (f) Admissions Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement… This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as licensee manually added verbiage after the admissions agreement was signed by R1’s POA which contradicted with the original terms, which poses a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: The Licensee has agreed to review Regulation 87507 on Admissions Agreements and submit a statement of understanding to CCL no later than 01/22/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 12/23/2022. When the LPA arrived, there were two (2) staff and six (6) residents present. The LPA was greeted at the door by staff, Eloisa Vasallo and the reason for the visit was explained. The Administrator, Lidia Medina arrived during the inspection. Entrance interview conducted. At 12:41 p.m., the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 12:48 p.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored under the kitchen sink locked and inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink. COMMON AREAS: At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. The LPA observed three residents watching television at the time of the inspection. The facility maintained a comfortable temperature. At 12:59 p.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and charged on 03/15/2023. The LPA observed a closet in the hallway with extra towels and linens. The LPA observed required postings throughout the common space. There is a working telephone on premises. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) GARAGE: The garage is kept locked at all times. The washer and dryer were observed inside the garage. The LPA observed detergents and cleaning supplies in the garage as well. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit. BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in bedroom #4. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms and found in compliance between 105- and 120-degrees Fahrenheit at the time of the visit. RECORDS: Records review began at 1:13 p.m.; six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 1:45 p.m., Review of Resident #1’s (R1’s) medical assessment dated 09/25/2023 revealed that R1 has no capacity for self-care and is neither on hospice nor has the facility submitted an exception request to admit or retain R1 at the facility. The Administrator stated they would be submitting a request to the Department to retain R1 at the facility. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) Three (3) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete. The current Administrator’s file was also reviewed, and it was complete. The last emergency disaster drill took place on 10/30/2023. MEDICATIONS: Medications review began at approximately 2:50 p.m.; medications are centrally stored in a locked cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents. At 3:08 p.m., a review of Resident #2’s (R2’s) centrally stored medication revealed that R2’s medication for Hydrocodone was logged on the centrally stored and destruction medication record (CSMDR); however, the wrong prescription number was written down. Staff corrected prescription number at the time of the visit. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 21, 2023