Incident investigation·September 25, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 11:22AM. The purpose of this visit is to conduct an investigation regarding three (3) self-reported incidents that occurred on 09/11/2025 and on an unknown date approximately two (2) months ago. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards, conducted interviews with three (3) staff members and attempted interviews with two (2) residents, and reviewed and obtained copies of pertinent records. On 09/11/2025, the Department received an incident report and SOC341 stating that on an unknown date approximately two (2) months ago, Staff #1 (S1) pushed Resident #1 (R1) onto their toilet causing it to break. The incident was reported by Staff #2 (S2) on 09/10/2025. R1 was assessed for injuries immediately after the incident was reported and observed no injuries on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and Adult Protective Services were notified. The facility conducted an internal investigation during which S1 and S2 were suspended and are no longer employed at the facility. ED stated it is unknown if the incident actually occurred due to conflicts and retaliation between S1 and S2. LPA discussed mandated reporting requirements and ED stated that a formal mandated reporter training will be conducted with all staff. LPA also attempted an interview with R1. On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 08:26AM, Staff #3 (S3) mistakenly administered Resident #2’s (R2) morning medications to R1 due to confusion of the residents’ similar room numbers. Report Continued on LIC 809-C. The medications administered to R1 consisted of Allopurinol 100mg, Atorvastatin 40mg, Gabapentin 100mg, Losartan 25mg, Quetiapine Fumarate 25mg and 50mg, and Sertraline HCL 100mg. R1 receives Quetiapine Fumarate 25mg in the evening, no other medications that were administered to R1 were on their medication list or orders. S3 observed the mistake immediately and notified facility management. R1’s primary care physician and responsible party were notified. Primary care physician advised for facility to monitor symptoms and not administer R1’s prescribed morning medications for the day. R1 was monitored for changes and did not have adverse effects besides increased sleepiness. S3 received additional medication administration training via online and in-person. LPA interviewed S3 who was knowledgeable in medication administration and verification techniques. The facility was previously cited within the last 12 months on 03/11/2025 and 04/24/2025 for medication administration errors. On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 11:55PM, Resident #3 (R3) left the facility unassisted through the back egress door, door #3, which leads to the exit gate. Staff heard the alarm ring and immediately went to the door where they observed R3 standing outside of the community perimeter gate on the sidewalk. Interviews stated that R3 was not outside of the facility for more than one (1) minute and R3 did not wander off the sidewalk. R3 had no injuries. R3 was diagnosed with a urinary tract infection (UTI) which contributed to R3’s confusion and wandering. Facility management held a meeting with NOC shift staff to discuss wandering prevention techniques as R3 tends to wander at nights. Staff have increased their supervision and sit with R3 in the dining room to keep busy as R3 enjoys their company and does not tend to wander if they are not alone. Facility management also conducted an in-person elopement training on 09/25/2025 . On 01/07/2025, the facility was previously cited for two (2) elopement incidents and have since increased the delayed egress time from 15 seconds to 30 seconds and replaced the alarms to louder ones that can be heard from the other side of the facility. LPA tested door #3’s delayed egress at 12:16PM which was functional and operating. Staff responded to the alarm immediately and cleared the alarm at 12:17PM. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was assessed in the amount of $250 for repeat violation. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.