Incident investigation·June 15, 2026

On June 15, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 6, 2026. During the visit, the LPA met with Anita Csukardi & Ace Huynh, Executive Directors to explain the purpose of the inspection. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 8, 2026, stating that Resident #1 (R1) had been given the wrong medication. On June 6, 2026, at 4 PM, the medication technician mistakenly verified only (R1's) last name without confirming the correct resident. Consequently, (R1) was administered medications intended for another resident with the same last name. As a result, both Metformin and Senna were given to (R1) in error, leading to hospitalization in the emergency room. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physicians Report (LIC 602A) (dated 07/27/23) and Medication List (dated 06/15/26), which confirmed that (R1) was not prescribed Metformin by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.