Incident investigation·October 6, 2025

At approximately 8:45AM, 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 09/19/2025. LPA met with Administrator Molly Morandi and reviewed records. The report states that on 09/19/2025, Client, C1, received their morning medication twice. Staff, S1, did not review the Medication Administration Record before giving C1 their medication. Physician was notified and C1 was observed. S1 was terminated and medication retraining has been conducted for all staff who handle medications. This is a repeat violation of the same regulation within a 12 month period, resulting in a civil penalty being issued in the amount of $250. 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.