Incident investigation·April 14, 2026

04/14/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met Interim Executive Director, Vivian Villegas. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 04/02/2026, stating that on 03/26/2026 during a med pass observation with pharmacy it was discovered that resident (R1) was out of a couple scheduled meds. Upon further investigation by the facility it was determined R1 had two medications that were last administered on 03/16/2026. A third medication was last administered on 03/20/2026 and a fourth medication was last administered on 03/22/2026. Per conversation with Resident Care Director, RCD stated when the med techs noticed R1 was running low on medication they started reaching out to R1s doctor via phone who turned out to not be R1s doctor anymore. RCD stated this previous doctor had done a courtesy refill at one point, causing confusion that he was R1s current doctor. RCD stated that there was a miscommunication with R1s family as to who was R1s real doctor, causing a delay in getting medication refills for R1. Once the facility was able to locate R1s real doctor, they were able to get medication refills. RCD stated they were given two wrong doctors before they were able to contact R1s family and receive R1s current doctor. Although no deficiencies were cited today, facility conducted in-service training and a copy was provided to LPA. Copy of report and LIC811 (Confidential Names) was provided to Interim Executive Director.