Incident investigation·May 13, 2026

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to complete a pre-licensing inspection. During this inspection, LPA followed up on special incident report submitted by the facility. LPA met with Compliance and Training Coordinator Julissa Aguirre and reviewed records. On 03/28/2026, a staff, (S1) was training to become a medication technician and gave a medication to a resident that was prescribed to the different resident. The medication was prepared in advance with the room number written on the medication cup. S1 handed a cup to a resident and when the cup was returned, S1 realized it was the wrong cup. Staff assessed the resident and verified there were no known allergies. Residents physician was notified and resident was monitored for adverse reactions. LPA requested staff refresher training on medication procedures and an updated medication procedure. This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Juliessa Aguirre and Appeal rights were given.