Incident investigation·April 16, 2026

On 4/16/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced case management visit regarding two self reported incidents that were reported to CCLD on 4/7/2026 and 4/10/2026. LPA met with Executive Director Glenda Bertucci and explained the purpose of the visit. The first incident report stated that on 3/29/2026 around 9:00 am, Staff two (S2) was preparing resident (R1's) medication when S2 observed that the expiration date on the medication bottle indicated that it expired on 3/5/2026. The incident report indicated that R1 was given expired medication of Amlodipine 2.5 mg from 3/5/2026- 3/29/2026. On 3/29/2026, S2 noticed the expired medication and notified S3 to verify the expired medication and S3 re-confirmed that the medication was expired. R1's order is Amlodipine 2.5 mg: take 1 tablet by mouth 2x daily at 9:00 am. Physician and POA were notified of the incident. R1 was not resulted injury or medical problem due to this incident. In-service training was provided to staff on 3/30/2026. The second incident report stated that on 4/3/2026 around 10:00 am, S1 was reviewing R1's Centrally Stored Medication and Destruction Record and observed that there was a discrepancy with medication dosage of R1's medication of Amlodipine 2.5 mg. S1 observed that R1 was given the Amlodipine 2.5mg but staff only gave R1 1 tablet per day due to the previous physicians order dated on 9/10/2025 that indicated to give R1 Amlodipine 2.5mg 1 tablet by mouth daily. When S1 was reviewing R1's documents S1 realized that the medication dosage was changed to Amlodipine 2.5mg: take 1 tab daily by mouth two times a day on the physicians order dated 12/29/2025 that was received from the Skilled Nursing facility when R1 returned back to the facility. Continued on LIC809C. Continued from LIC809. S1 stated that R1 was given 1 tablet of Amlodipine 2.5 mg daily as opposed to 1 tablet two times a day from 12/29/2025 to 4/3/2026. S1 stated that R1 was sent out to the hospital on 11/21/2026 and was later admitted to a Skilled Nursing Facility from 11/26/2025 - 12/29/2025. S1 stated that the Skilled Nursing Facility changed the dosage amount on 12/8/2026 while R1 was still attending the Skilled Nursing Facility. Physician and POA were notified of the incident. R1 did not result in injury or obtain ill side effects due to this incident. In-service training was provided to staff on 4/3/2026. S1 acknowledged that both the under dosage and the expired medication was overlooked by staff. LPA interviewed S1 and S2. LPA attempted to interview S3. LPA reviewed and obtained R1's MAR (Medication Administration Record) from September 2025 - April 2026, updated Needs and Services Plan, Alert Charting report, Prescriber notification medication error report regarding Wrong Time and Wrong Dose, Physicians Order dated 9/10/2025, and Order Summary Report (Change of dosage) dated 12/29/2025. LPA also reviewed and obtained the Med Tech to Med Tech Communication Log, LIC500 (personnel Report), Resident Roster, and staff training. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty. Exit interview conducted with Glenda. Appeal Rights and a copy of this report provided.