Incident investigation·March 10, 2026

At approximately 11:10 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with Administrator, Eugene Pascual and Health Services Director, Tosha Chowdory. Today's visit was in regards to two (2) Incident Reports (IRs) for Resident 1 (R1) and for Resident 2 (R2) submitted to Community Care Licensing (CCL) by the facility. The IR for resident R1 states that on 2/25/2026, while being transferred by one (1) staff member (S1) resident R1 fell. Facility Progress Notes for resident R1 indicate that they did not directly fall, but instead was lowered to the ground by staff member S1. Paramedics were called and resident R1 was taken to a local hospital. Resident R1 did not suffer any fractures as a result of this incident. Resident R1's Individualized Service Plan states that two (2) staff members are needed to assist transferring resident R1. As the facility did not follow residents R1's Individualized Service Plan, the facility will be cited for this deficiency. During today's visit, LPA was informed that staff members carry phones that show in the individual care needs of each resident to whom they are assigned. On 2/26/2026 the facility conducted Care Plan training to reiterate to staff members that they need to review residents care needs and to follow the Individualized Service Plans of residents. As a result of this incident, staff member S1's employment with the facility was terminated. As the facility has already conducted Care Plan training, the deficiency will be cleared during today's visit. The IR for Resident R2 states that on 2/17/2026, resident R2 was mistakenly given the wrong medications. At 7:00 AM, staff member S2 was preparing medications for the morning medication pass. They put medications for a third (3) resident (R3) in a cup for dispensing. Staff member S2 then realized that resident R3 had left the facility for a doctors appointment. Staff member S2 contacted the family member escorting resident R3 to their doctors appointment. The family member asked that the medications be held until resident R3 returned to the facility. Continued on 809-C... ...Continued from 809 At approximately 2:00 PM, resident R2 requested their normal afternoon medications. Staff member S2 then proceeded to add resident R2's medications to cup that contained resident R3's missed morning medications. As a result of this error, resident R2 mistakenly took medications intended for resident R3. The facility immediately had resident R2 assessed by a Registered Nurse and placed resident R2 on alert charting with hourly checks of vital signs. R2's emergency contacts were notified. Additionally, the facility's Medical Director (a licensed Medical Doctor) was on site and they also monitored R2's condition. Resident R2 was kept on alert charting for 72 hours. Resident R2 suffered no adverse effects of the medication error. The facility will be cited for this medication error. The facility took disciplinary action against staff member S2. Staff member S2 also underwent four (4) days of retraining and shadowing the lead Medical Technician (Med Tech). Additionally, all the facility's Med Techs underwent Medication Policy training. As this disciplinary step and retraining was already completed, the deficiency will be cleared during today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names, Appeal Rights and Letters of Deficiency Citations Cleared discussed and provided to Administrator Pascual. Signature on form confirms receipt of documents.