Incident investigation·July 30, 2025

On 07/30/2025 at 10:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported medication error that occurred on 07/20/2025. Health Services Director, Brenda Silva self-reported the incident on 07/24/2025. LPA met with Care Director, Maryrose Vinarao, and explained the purpose of the visit. General Manager was unavailable during today's visit. LPA received an incident report that on 07/24/2025 Resident 1 (R1) was given a PRN medication after the medication has been discontinued. During the visit, LPA reviewed R1's After Visit Summary, Medication List, Medication Administration Training, Physician's Fax Report, Individual Narcotic Record, and Email Correspondence with R1's family. Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the medication error. Interview with Care Director revealed that Staff 1 (S1) gave R1 the PRN medication before checking the Medication Administration Record (MAR). The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalty. Exit interview conducted with Care Director. Appeal Rights and a copy of this report provided.