Incident investigation·June 25, 2025

On 6/25/2025 at 2:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 6/20/2025. LPA met with Executive Director, Julie Mammad and Assistant Resident Care Director, Dolores Prince. LPA informed them the reason for the visit. Based on the incident report received on 6/20/2025, resident (R1) took R2's medications. R1's family and doctor were notified. Med tech will receive training on medication administration. During visit, LPA interviewed staff and reviewed R1's file including medical assessment, physician's notification, and care notes. Staff stated R1 was monitored for 3 days after taking the incorrect medications and was observed with no ill effects. Facility had a meeting with residents, family, and staff regarding medication administration and regulatory requirements. Med tech was given some additional training and will receive more training in later days. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.