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13 | On 09/10/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit. LPA introduced self, stated purpose of visit, and allowed entrance. LPA met with Executive Director (ED)/Administrator (ADM), Jeffrey Toomer to conduct visit.
This department investigated the above allegation, during the investigation, facility was toured, interviews
conducted and records reviewed. Based on information gathered during interviews and incident report received by department on 5/23/2025, R1 was administered medication belonging to both R2 and R3. R1 and R2 were current residents and R3 last resided at facility on 3/30/25 and medication was still at facility as of date of complaint.
The preponderance of evidence standard has been met, therefore the allegations of facility staff did not properly dispose of resident's medication upon termination of services and facility staff did not dispense medications to residents as prescribed are found to be SUBSTANTIATED.
Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.
Exit interview conducted with Executive Director. A copy of this report and appeal rights provided for facility records.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/26/2025
Section Cited
CCR
87465(i) | 1
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7 | Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: | 1
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7 | Executive Director to provide copies of destruction records for R3 to department by plan of correction due date. |
 | 8
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14 | **This was not met as evidenced by R3 last resided in facility on 3/30/25 and medication was still on site and had not been destroyed as of 5/21/25 when complaint was filed.. | 8
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14 | |
Type B
09/26/2025
Section Cited
CCR
87464(f)(1) | 1
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7 | (f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in | 1
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7 | Staff involved in incident were terminated on 5/26/25 & 5/30/25 and additional staff training provided regarding medication management.
Executive Director to provide copies of training records to department by plan of correction due date. |
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14 | the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. **This was not met as evidenced by R1 R1 was administered medication belonging to both R2 and R3. | 8
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