Incident investigation·February 6, 2026

On 2/6/2026 at 10:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards incident report received 2/5/2026. LPA met with Executive Director (ED), Jennifer Coons and explained the reason for the visit. It was reported that on On 1/31/26, at approximately 9am, resident one (R1) was provided medication of another resident two (R2), in error by staff one (S1). ED states that S1 has since resigned from their position. ED also states that S1 previously had made medication errors/process errors and they received additional training. R1 did not sustain any negative side effects as a result of this error. ED states that S1's responsible parties where notified of the incident. ED states that R2 was not notified but that they took responsibility in notifying the pharmacy of the missing meds and replacing them. 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.