Incident investigation·September 10, 2025

Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to conduct a Case Management inspection to follow-up on an incident report received at the CCL office on 8/27/2025, regarding a medication error. LPAs met with Resident Service Director , RSD, Nhi Nguyen and discussed the details of the incident. On 8/17/2025 at approximately 11:00pm Incoming med tech on duty noticed new orders for R1 for Hydrocodone - Acetaminophen 5-325mg. Orders are to take half a tablet by mouth every 6 hours as needed for pain. S1 signed and gave R1 a whole tablet of Hydrocodone instead of half as ordered. During the visit, LPAs reviewed and received a copy of R1's MAR, and Progress Notes. RSD Nhi indicated that the facility contacted the appropriate parties such as R1’s physician and family. R1 was placed on monitoring and did not show any side effects from the medication error. RSD Nhi conducted in-service training on medication for all med techs. CONTINUE ON LIC 809C CONTINUE FROM LIC 809 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 a copy of this report and appeal rights provided.