Incident investigation·October 31, 2025

On 10/31/2025 at 9:30AM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conduct a Case Management visit regarding an Unusual Incident Report (LIC624) received on 10/11/2025. Incident involved the wrong AM medications being given to a resident, with resident not being transferred to a hospital and had continued monitoring for any change of condition. LPAs met with Business Office Manager Claudia Redditt and Marketing Director Molly Gleason-Kodama, and explained the purpose of the visit. Facility is currently at 186 residents with a max capacity of 230 residents. During the visit, LPAs collected the following documents: resident roster, employee roster, R1's Medical Assessment (LIC602), R1's Appraisal Needs And Services, and R1's medication list. LPAs spoke to staff, S3, to discuss what happened when the incident occurred and what steps have been taken to ensure that it does not happen again. Staff stated that, at the time of the incident, S1 had medications for another resident, R2, in the medication cup, but was rushing to get meds passed. As a result, the medication was given to R1, and S1 immediately reported the incident to S2 and S3. R1 was monitored continuously for 48 hours and had no problems. To prevent occurrences in the future, licensee will implement changes in how medications are dispensed. Instead of preparing medications for all residents at once and passing them out, medtechs will prepare medications at each individual apartment, bring the medication cart with them versus the small box of prepared medications currently being done. In addition, S1 is no longer on medtech duty and is performing caregiver duties. Continued on LIC809C..... Continued from LIC809..... During the visit, a citation was issued for the reported incident. On 10/11/2025 at 7:50AM, medtech gave the wrong medications to a resident. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and a copy of this report, along with appeal rights, was provided to the Business Office Director.