Incident investigation·May 9, 2025

On 05/09/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPA met with Executive Director (ED) Anyssa Hill and explained the purpose of today's visit. The purpose of today's visit is to follow up on a Unusual Incident/ Injury Report that was sent to the Department on 04/28/2025. LPA received an incident report regarding a medication error. It was reported that during afternoon medications. Facility staff mixed up Resident #1 (R1) medication cup and Resident #2 (R2) medication cup. R1 did received R2s medication Seroquel 25mg. Facility staff did catch this error before R2 received any medication. R1 did not have any reaction to the medication. Facility staff immediately called poison control and R1s doctor. R1s responsible party was present at the facility during time of incident. Based on this information, deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties. Exit interview conducted. Appeal rights provided. Copy of the report left at facility.