Incident investigation·October 30, 2025

Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Case Management visit to facility to check the health and safety of residents in care. LPA met with Director Zara Poghosyan and Administrative Assistant Diana Rios and explained the reason for today's visit. At 9:45am LPA discussed incident in question regarding medication error in which Wellness Director Ambresa Bree Thomas was contacted via phone to assist with information. At 10:00am - 1:15pm LPA reviewed Residents (R1 and R2) Electronic Medication Administration Records (EMAR). Director, Administrative Assistant, and Wellness Director assisted during review. Based on record review and interviews the following errors were found: R1 was given the prescription medication on September 25, 2025 by MedTech. R1 was given medication that was prescribed for R2 by MedTech. Medication error was not discovered until a week later. Upon distribution R2's scheduled prescription medication was discover missing. Medication is listed on residents Face Sheet and Emergency Information Sheet (Info) and EMAR system. The medication for both (R1) and (R2) are alike but have different milogram dosages. The requirement was not met by Title 22 Regulation and resulted in a medication given in error. Deficiency is cited per California Title 22, Division 6 Chapter 8. See LIC 809D. Exit interview was conducted with Director Zara Poghosyan. A copy of the report and appeal rights was provided.