Incident investigation·March 19, 2026

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report regarding a medication error received by Community Care Licensing (CCL) on March 16, 2026. The report was submitted by Wellness Director (WD) Veronica Mata, LVN. LPA was greeted and granted entry by Executive Director (ED) Carmen Galicia, and the purpose of the visit was explained. During the inspection, LPA toured the facility with ED Galicia and observed Resident 1’s (R1) room. R1 was not present at the facility and is currently hospitalized. LPA conducted health and safety checks on residents in care and confirmed they were doing well, with no health or safety concerns observed. The facility was observed to be clean, organized, and free of hazards. WD Mata reported that R1 was transported to the hospital following the medication incident. Hospital staff later confirmed that R1 was cleared of medication intoxication. WD Mata further stated that additional, unrelated medical conditions were identified during hospitalization, and R1 remains admitted for treatment of those conditions. ED Galicia reported that the medication error occurred during the evening shift when Med Tech staff administered medication to the wrong resident due to confusion between residents with the same first name. Staff failed to verify the residents’ full names prior to medication administration, which resulted in the error. ED Galicia stated that both Med Tech staff involved were reprimanded for the incident and have been (Case Management Report continued on LIC809C) removed from medication administration duties pending completion of retraining. LPA requested and reviewed copies of R1’s resident file, including relevant medication records. Based on the information obtained, the following deficiency is being cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director Carmen Galicia. A copy of this report, along with appeal rights, were provided to the facility .