Incident investigation·November 4, 2025

On 11/4/25 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an self-reported incident report received 11/3/2025. LPA notified Licensee Erlinda Gines over the phone that they were at the facility and Licensee arrived at approximately 11:20 AM . It was reported that R1 was administered the incorrect medication for approximately four (4) days and had to be sent out to the emergency room. Licensee states that the oversight was made because the pharmacy sent out medications for an individual who does not reside at the facility and they did not notice. Licensee noticed the name on the medications belonged to someone else after R1 was sent out. Licensee states that R1 is still at the hospital but is expected to make a full recovery. LPA went over proper medication procedure and logging new medications with the Licensee. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.