Incident investigation·August 6, 2025

On 08/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/25/25. LPA met with Administrator, Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 08/04/25 to CCL stated that resident, R1 was sent to hospital on 07/25/25 , after R1 was given the wrong insulin dose by staff. The incident report indicated that R1 was given wrong insulin dose around 11AM on 07/25/25. Staff notified immediately of the facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility on 07/25/25. Facility notified R1s physician and the responsible party regarding medication error. LPA was notified by administrator that the facility took appropriate action with staff regarding this incident according to the facility policy who was associated with this incident . Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medication to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) 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.