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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 07/18/2025
Date Signed: 07/18/2025 01:40:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250626152114
FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:KHATERA BAHADORYFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 70DATE:
07/18/2025
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Nestor MedezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff does not respond to resident's call button in a timely manner.
Staff did not safeguard resident's medication.
Staff did not administer medication to a resident in care.
INVESTIGATION FINDINGS:
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On 07/18/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with the Executive Director, Nestor Mendez, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today's visit, LPA interviewed Staff S8 and conducted an additional interview with S2, and delivered findings.
During the initial visit conducted on 07/01/2025, LPA toured the facility, interviewed Staff S1, interviewed Residents R2-R6, conducted a medication review for Resident R2 and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule (for June 2025), Pendant Logs (for June 2025), Consultant Dietitian Report Card (dated April 2025), Monthly Menu, resident Physician’s Report, Physician Orders, Needs and Service Plan, Medication Administration Record (MAR) (for June 2025), and resident Charting Notes.
During a subsequent visit conducted on 07/11/2025, LPA interviewed Staff S2-S7, interviewed Residents
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 07/18/2025
NARRATIVE
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R1, R4, and R6, conducted a medication review for four (4) residents, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Resident R5’s Physician Report, Physician Order, Needs and Service Plan, and eMAR for R1-R5 for July 2025.
The investigation revealed the following:
Allegation: Staff does not respond to residents call button in a timely manner
The allegation alleges that staff respond to residents call buttons within 30 to 60 minutes.
During the facility tour, LPA visited Residents R1-R5 in their rooms or in the facility. During each visit, the residents’ pendants were pressed upon meeting. The following times were the response times to each call: R1 (room 513) staff responded in 6 minutes, R2 (in bistro area) staff responded in 4 minutes, R3 (room 221) staff responded in 7 minutes, R4 (common area) staff responded in 6 minutes, and R5 (room 133-pulled cord) staff responded in 5 minutes.
LPA received and reviewed Pendant Logs for five (5) Residents for the month of June 2025. LPA observed three (3) out of five (5) residents’ calls for assistance were not answered in a timely manner. LPA observed the following for Resident R1, there were 21 times, in the month of June 2025, that took staff over 15 minutes to clear the call. For Resident R3, there were 21 times, in June 2025, that took staff over 15 minutes to clear the call. For Resident R4, there were 45 times, in June 2025, that took staff over 15 minutes to clear the call.
During interviews with Staff S1-S7, were asked how long it takes to respond to a resident’s pendant or cord pull, seven (7) out of seven (7) stated it should take 5 to 10 minutes to respond to residents’ calls for assistance.
During interviews with Residents R1-R8 , were asked if staff respond to the pendant and/or pull cords in a timely manner, four (4) out of eight (8) stated they have had to wait an extended period of time before staff came to provide assistance.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.
Allegation: Staff did not administer medication to a resident.
The allegation alleges that a resident was not administered their medication.
During the facility visit, LPA audited the Centrally Stored Medication, Physician Orders, and eMAR, from July 1, 2025 to July 11, 2025, for Resident’s R1-R5. LPA observed five (5) out of five (5) residents medications were not consistent with properly documented records. The audit revealed Resident R1 had two extra pill in
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 07/18/2025
NARRATIVE
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their prescription Melatonin 5mg bubble packet, on the eMAR it was signed off that it was provided and one day was out of the community. For the PRN medication Benzonatate 100MG the bubble pack was missing 12 doses and the eMAR documented 11 doses provided to R1. For the PRN Calcium Carbonate 500MG the bubble pack was missing 1 dose that was not documented as provided on the eMAR. For Resident R2, on the eMAR it was signed off that evening medications for Vitamin D3 125MCG and Vitamin E 400IU were provided on July 1, 2025, and both doses were in the bubble packet. For Resident R3, on the eMAR it was signed off that on July 10, 2025, R3 did not receive the 7AM and 1PM dose of Clonazepam 0.5MG due to staff error, the primary care physician was made aware. Additionally, the medication Donzepezil 10MG had an extra dose in the bubble pack, the medication Finasteride 5MG had three (3) extra doses in the bubble pack, the medication Olanzapine 15MG had a extra ½ dose in the bubble pack, and the medication Trazodone 150MG had and extra dose in the bubble pack. All days on the eMAR indicate medications were provided. For Resident R4, the medication Amlodipine 5MG had an extra dose in the bubble pack, the medication Atorvastatin 20MG had an extra dose in the bubble pack, the medication Glipizide 5MG had an extra dose in the bubble pack, the PRN medication Acetaminophen 325MG was provided and documented 35 doses were provided and the bubble pack has 36 doses missing. For Resident R5, the medication Amlodipine 2.5MG has 3 extra doses in the bubble pack, Docusate Sod 100MG had 11 extra doses in the bubble pack, Melatonin 5MG had 2 extra doses in the bubble pack.
During interviews with Staff S1 -S7, were asked if residents medications are provided as prescribed, seven (7) out of seven (7) stated yes, residents medications are provided as prescribed.
During interviews with Resident R1-R8, were asked if they receive their medications as prescribed, four (4) out of eight (8) stated they do not receive their medications as prescribed and they are usually late. Additionally, during interviews Resident R1-R8 were asked if there was a time, they did not receive their medications, three (3) out of eight (8) stated there has been a time they did not receive their medications. Two (2) out of eight (8) of the residents do not receive assistance with medications.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.
Allegation: Staff did not safeguard resident medication
The allegation alleges that staff lost resident medication and staff forgot to order resident medication.
During medication review LPA reviewed the Centrally Stored Medications and the Physician Orders for five (5) residents. During the review of Centrally Stored Medications, four (4) out of five (5) residents Centrally Stored Medications were consistent with medications listed on the Physician Orders and eMAR. Staff were
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 07/18/2025
NARRATIVE
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unable to locate the PRN medication Diphenhydramine HCL 25MG for Resident R3. There were no notes if the medication had been discontinued or was being refilled.
During interviews with Staff S1-S7, were asked if a resident’s medications have been lost or misplaced, four (4) out of seven (7) stated there have been instances when the medication was not filled yet and residents missed medications.
During interviews with Residents R1-R8, were asked if the facility has lost or misplaced their medications, four (4) out of eight (8) stated they have not received their medications due to them being filled. Additionally, one (1) out of eight (8) stated they did not receive their medication due to staff not being able to locate it.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.
An exit interview was conducted with Executive Director, Nestor Mendez, and a copy of this report and appeals right was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250626152114

FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:KHATERA BAHADORYFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 70DATE:
07/18/2025
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Nestor MedezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff did not serve meals in a timely manner.
Staff is serving food that is not of quality.
INVESTIGATION FINDINGS:
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13
On 07/18/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with the Executive Director, Nestor Mendez, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today's visit, LPA interviewed Staff S8 and conducted an additional interview with S2, and delivered findings.
During the initial visit conducted on 07/01/2025, LPA toured the facility, interviewed Staff S1, interviewed Residents R2-R6, conducted a medication review for Resident R2 and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule (for June 2025), Pendant Logs (for June 2025), Consultant Dietitian Report Card (dated April 2025), Monthly Menu, resident Physician’s Report, Physician Orders, Needs and Service Plan, Medication Administration Record (MAR) (for June 2025), and resident Charting Notes.
During a subsequent visit conducted on 07/11/2025, LPA interviewed Staff S2-S7, interviewed Residents
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 07/18/2025
NARRATIVE
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R1, R4, and R6, conducted a medication review for four (4) residents, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Resident R5’s Physician Report, Physician Order, Needs and Service Plan, and eMAR for R1-R5 for July 2025.
The investigation revealed the following:
Allegation: Staff did not serve meals in a timely manner
The allegation alleges that dinner is to be served at 4:20PM and was not served till 6PM.
During the facility visit, LPA observed residents began coming to the dining room at 11:40 AM and lunch was served at 11:54AM. LPA observed two (2) servers providing meals to residents. LPA observed residents order their food from the menu at 12PM and were served their drinks, soup, and fruit at 12:03PM, and their main course was served at 12:19PM. LPA observed an additional table order their food at 12:06 PM, they were served their drinks, soup, and fruit at 12:09PM, and their main course was served at 12:25PM. LPA observed a resident arrive at the dining room at 12:33PM, their order was taken at 12:34PM, they were served drinks at 12:37PM, soup and fruit were served at 12:39PM, and the main course was served at 12:47PM.
During interviews with Staff S1-S8, were asked if meals are served in a timely manner, eight (8) out of eight (8) stated meals are served to residents in a timely manner.
During interviews with Residents R1-R8, were asked if they are served their meals in a timely manner, five (5) out of eight (8) stated they receive their meals in a timely manner.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Allegation: Staff is serving food that is not of quality
The allegation alleges the food that is served is not fresh.
LPA observed lunch service being served. LPA observed fresh fruit, soup, steak, and vegetables served. LPA observed the food was fresh. LPA heard multiple residents stating the food and vegetables were delicious, when asked how the food was. Additionally, LPA heard a table discussing how delicious the food was. In the Bistro, LPA observed fresh fruit, Nutri Grain Bars, Chex Mix, Oreos, and chips available for residents.
During the facility tour, LPA inspected the kitchen food supply. LPA observed there was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed the food was properly stored, labeled, and dated. LPA observed food to be of good quality, and is commercial food approved by federal, state, and local authorities.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 07/18/2025
NARRATIVE
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During record review, LPA received and reviewed the Consultant Dietitian Report Card for Assisted Living dated April 2025 that indicates in the section for Food Preparation and Meal Service “Meals served at the designated times per State regulations,” “Proper food handling: avoids cross-contamination,” “Food temperature meets standards and recorded (Hot food>135 deg F, Cold food <41 deg F) at the point of service on steam table,” and Snacks and beverages available throughout the day; Hydration stations available.” In the section Food Sanitation/Safety/Storage it is indicated the “Food is purchased from an approved source and considered satisfactory,” “Facility thaw foods properly with pull dates,” and “Staff prevents cross-contamination.” Additionally, LPA received and reviewed General Ledger Report for food purchased through Freshpoint Southern California, INC and Sysco Riverside, INC for the months of May and June 2025.
During interviews with Staff S1-S8, were asked if the residents are provided quality food, eight (8) out of eight (8) stated residents are served quality food.
During interviews with Residents R1-R8, were asked if they feel the food provided is fresh and of good quality, seven (7) out of eight (8) stated they feel the food is fresh and of good quality.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted with Executive Director, Nestor Mendez, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition..., residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) to care, supervision, and services that meet their individual needs and are delivered by
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A new paging system is being installed on 07/19/2025. The calls are all routed to the front desk who is able to informs care staff as well as the page they receive. Training for the new paging system and reponse times will be conducted before the POC and emailed to LPA at Wendy.Gibbs@dss.ca.gov
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by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This was not met as evidenced by interviews and record review. Pendant logs indicated 21 instances for R1 and R3, and 45 instances for R4 that took staff over 15 minutes to respond to residents’ call for assistance.
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Type B
07/28/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with
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In-Service logs will be sent for training regarding MAR verification after each pass. If any thing is observed med tech will be spoken with during cross over. Logs will be sent to LPA by POC at Wendy.Gibbs@dss.ca.gov
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self-administered medications as needed.

This requirement was not met as evidence by record review, observation, and interviews, Residents R1-R5 were not provided with medications as prescribed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 11-AS-20250626152114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198601661
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored
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The medication room has been expanded to better organize overflow of medications. Training will be conducted to ensure residents medications are logged and stored properly when they arrive at the facility. Logs will be sent to LPA by POC to Wendy.Gibbs@dss.ca.gov
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medication.
This requirement was not met as evidence during record review, observation, and interviews, during medication audit staff were unable to locate R3’s PRN Diphenhydramine HCL 25MG and had no notes of the medication being discontinued.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9