Incident investigation·June 10, 2025

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report regarding medication error received by Community Care Licensing (CCL) on May 21, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige, LVN. LPA was greeted and allowed entrance into the facility by facility staff. Executive Director (ED) John Goodwin and HWD Suzette Paige arrived shortly to assist with the visit. LPA explained the reason for the visit. During the inspection, LPA and ED toured the facility and checked on Resident 1 (R1). R1 was observed to be fine and was using the oxygen machine when LPA came to check on them. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA requested and reviewed copies of R1's resident file. Based on the report received the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director, John Goodwin and a copy of this report was provided at exit.