Incident investigation·August 15, 2025

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an Unusual Incident Report submitted by the facility on 07/30/2025. LPA met with Administrator Molly Morandi and reviewed records. On 07/27/2025, Resident, R1, morning medication was not administered as ordered. The medication error was realized on 07/29/2025, while conducting a review of the past mediation administration records. All required notifications were made. Administrator revised medication protocols to ensure accountability for each residents medication. All staff have been scheduled for retraining on medication administration being conducted by a Registered Nurse. LPA received copies of completed training documentation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Molly Morandi and Appeal rights were given.