complaint·October 31, 2023

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Bonilla and explained the reason for the visit. It was reported that staff mismange Resident #1 (R1)'s medication. To investigate this allegation on 10/31/2023 between 1:00pm and 2:30pm, facility records were reviewed. Between 3:00pm and 3:30pm, staff interviews were initiated. Staff interviews revealed that approximately six weeks ago a medication error occurred. R1 was given Resident #2 (R2)'s medication and R2 was given R1's medication. The medication was mixed up by a former staff member. Staff #1 (S1) was terminated and no longer works at the facility. Between 3:35pm and 3:50pm, LPA interviewed R2. Interviews confirmed what staff told LPA. R2 stated that their medication was mixed up. Based on interviews there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.