Incident investigation·October 1, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:03 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 09/17/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED), the Director of Assisted Living (DOAL), and the Business Office Manager (BOM) between 10:05 AM and 11:53 AM. The self-reported incident report stated that Resident #1 (R1) had missed administration of Medication #1 (M1) on 09/17/2025. DOAL and facility staff conducted a review of the resident’s medications and observed that M1 had not been on hand at the facility since 08/04/2025. DOAL made contact with R1’s hospice company on 09/17/2025 and obtained a refill of M1 that same day. R1’s family was notified of the incident at the time of its occurrence. R1 was medically evaluated by a hospice nurse at the time of the incident and no adverse reactions to the missed medications were noted. The facility has since conducted in-service training with the employees involved and has coordinated with the hospice company, veterans affairs, and R1’s family to ensure there is no further delays in obtaining R1’s medications. During today’s visit ED provided LPA with a copy of the facility’s in-service training sign-in sheet that was conducted in response to this incident. Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 9099-D.) Exit interview conducted and copy of the report and appeal rights were issued.