Incident investigation·April 22, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 11:21AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 04/12/2025. Upon arrival, LPA met with Executive Director (ED) Brian Larios and staff. Entrance interview conducted. During today's visit, LPA interviewed ED and Health and Services Director (HSD) Ian Gadea, conducted a brief physical plant tour, and observed the medication office in the memory care unit. On 04/21/2025, the Department received an incident report stating that on 04/12/2025 at 08:15AM, Resident #1 (R1)’s Carbamide Peroxide 6.5% ear drop medication was incorrectly administered in R1’s eye by Staff #1 (S1). Three (3) of five (5) drops were administered and the error was observed immediately as R1 reported pain in their left eye. R1 reported burning sensation, redness, and blurry vision. Eye wash rinse was utilized without any relief of symptoms. Facility staff called 9-1-1 and R1 was transported to the emergency room where R1 was prescribed antibiotics. R1’s family was notified of the incident same day. The facility responded quickly and effectively to relieve R1’s symptoms. As of 04/12/2025, S1 is no longer handling medications. HSD and ED stated that there are no current plans of S1 returning to handle medications. HSD stated that additional training will be held, and staff will be reminded to read all medication labels and instructions prior to administering. Continued on LIC 809-C. At 11:33AM, LPA observed the facility’s procedures for administering and documenting medications, and observed residents’ Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Records (CSMDR). Medication carts are kept locked. All medications are documented and logged with current administration instructions, RX number, date filled/started, prescribing physician, quantity, and expiration dates. The facility utilizes a digital MAR system and retains physical copies of CSMDRs. No concerns were noted. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.