Incident investigation·December 18, 2025

On 12/18/2025 at 9:55 a.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding medication related incident reports received by the Community Care Licensing Division (CCLD) on 12/09/2025, 11/20/2025, 10/20/2025 and 07/03/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr and explained the purpose of the visit. The case management visit was conducted due to multiple Unusual Incident Reports (UIRs) submitted by the facility over several months involving medication administration errors. CCLD received a UIR regarding an incident that occurred on 12/07/2025, which indicated that Resident (R1) requested a PRN medication for agitation; however, Staff (S1) administered an anti-diarrheal medication instead to R1. CCLD also received a UIR for an incident that occurred on 11/19/2025 at approximately 5:00 p.m., which indicated that R2 was inadvertently administered the wrong medication during the evening medication pass by S4 and S5. During interviews with S2 and S3, it was stated that the medication error occurred while S5 was training S4. LIC809-C Continued... LIC809-C (Page 2) Additionally, CCLD received UIRs documenting two medication related incidents that occurred on 10/07/2025 and 10/12/2025. The report for 10/07/2025 indicated that R3 was not administered a prescribed medication patch; however, it was documented and signed by S7 as having been given. The report for 10/12/2025 indicated that S7 administered a medication to R4 by sprinkling it on food. S7 stepped away after providing the food to R4. Subsequently, a guest consumed the food containing the medication. During interviews with S8, it was stated that when S7 stepped away, R4 offered the food containing the medication to the guest, who was seated at the dining table with another resident. During interviews conducted on 08/27/2025, S2 and S3 stated they were not aware of any documented follow-up notes or Plan of Correction addressing the medication errors. Both staff reported that the Medication Technician, S7, responsible for administering the incorrect medication was no longer employed at the facility. CCLD also reviewed a UIR regarding an incident that occurred on 07/03/2025, which indicated that R5, all memory care residents, missed their morning medications due to staffing issues after S9 tested positive for COVID-19 and left the facility. The report further stated that S10 from another community arrived to assist; however, the time window for the morning medication pass had elapsed. LPA obtained the following documents: R4's physician's report (LIC602-A), fax confirmation requesting an updated LIC602-A (dated 10/15/25), doctor's orders for crushed/sprinkled medications in foods/liquids and copy of S9's time card (dated 07/01/25 thru 07/10/25). As a result of the above findings, deficiencies were observed (see LIC 809D) and cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted, and a copy of this report along with appeal rights was provided.