Incident investigation·February 12, 2026

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit regarding a recent incident report submitted 02/09/2026. The Serious Incident Report (SIR) states Resident #1 (R1) was given the wrong medications by Staff #1 (S1). The medications were prepared for multiple residents and S1 handed R1 the wrong cup. Upon noticing, the facility immediately contacted R1’s physician and responsible party by phone and notified the Department via fax. The facility was instructed by the physician to monitor the resident for any changes as the resident was not in any immediate danger. R1 did not experience any change in condition. Subsequently, S1 completed additional training and has not had a repeated incident to date. A review of facility files shows that S1 was fingerprint cleared and completed all training. LPA randomly selected three (03) MedTech files all of which had completed their training. A copy of the completed training logs and training material was provided. (CONT. on LIC809-C) On 12/15/2025, LPA conducted a Case Management visit for a similar medication mismanagement incident. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): No other heath and safety hazards noted during the visit. Nothing further at this time. Exit interview conducted and a copy of the report was issued.