Incident investigation·October 6, 2025

On 10/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred around 09/16/25. LPA met with Administrator Stephen Macdonald and staff LVN, Eva Bowlin and explained reason for visit. Incident Report (LIC 624) submitted by facility on 09/26/25 to CCL stated that resident, R1 did not receive their prescribed medication Carbamazepine ER 400mg tab 8am, 8pm dose on 09/17/25 and 09/18/25 as facility ran out for this medication for R1 per their physician’s order. Record review and staff interviews indicated that staff did not notice till 09/15/25 morning that R1 has no medication to administer and contacted R1s pharmacy to refill the medication. Facility notified R1s physician and responsible party regarding this matter. Based on incident report, staff interviews and medication record review from the facility, It was determined that facility did not administer prescribed medication to R1 which poses a immediate health and safety risks to residents in care. Based on gathered information, deficiencies are cited per pursuit to California Code of Regulations, Title 22, Section 87465(a)(4) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.