Incident investigation·October 22, 2025

On 10/22/2025 at 12:00 PM, Licensing Program Analysts (LPAs) P.Manalo and K.Nguyen conducted an unannounced Case Management visit regarding a self-reported incident report. Executive Director, Beena Kumar self-reported the incident on 10/15/2025. LPAs met with Judith Gitonga and explained the purpose of the visit. Executive Director was unavailable during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated that R1 was given a medication in error of an additional dosage that occured on 10/09/2025. During the visit, LPAs interviewed Staff 1 (S1) and Staff 2 (S2) regarding the medication error. S2 admitted there was a medication error due the change of medication dosage after the medication was refilled by the pharmacy. LPAs will be requesting for the following documents such as hospice's Patient Care Order, Medication Administration Record (MAR), Medication Order Summary, Resident Roster, Staff Contact Information, and Narcotic Log by 10/30/2025. The Facility was 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 Penalties. Exit interview conducted with Gotinga. Appeal Rights and a copy of this report provided.