Incident investigation·March 26, 2026

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 02/21/26 . LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report, IR (LIC 624) submitted by facility on 02/21/26 to CCL stated that resident, R1 was given wrong morning medications on 02/21/26. IR indicated that on 2/21/2026 at approximately 9:00 AM, staff made a medication error and administered medications intended for another resident to R1. The medications administered by error were Buspirone 5 mg tablet, Donepezil 10 mg tablet and Vitamin B12 1000 mcg tablet. Staff notified immediately of the facility’s management regarding the medication error. Facility notified R1’s physician, responsible party and other required agencies regarding this medication error. LPA was notified that R1 was doing fine at the facility as of today. Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medications to R1 which poses a immediate health 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. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months. The report was reviewed, appeal rights and a copy of this report was left at the facility.