Complaint·June 11, 2026

experiencing symptoms and was sent to the hospital for evaluation. ED Goodwin confirmed that Staff 1 (S1) self-reported the medication error and acknowledged that the wrong medication had been given to R1. Staff 2 (S2), who was present at the time, confirmed that S1 did not follow the facility's medication administration procedure and administered medication to the wrong resident. Resident 2 (R2), whose medication had been mistakenly given to R1, also confirmed that the error was discovered after questioning the medication they received. Based on LPA’s interviews and information obtained during the investigation, the Department determined that staff failed to administer medication as prescribed. Therefore, the allegation mentioned above has been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Executive Director (ED) John Goodwin and a copy of this report and appeal rights were provided to the facility