Incident investigation·February 24, 2026

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Irma Sterling, Resident Services Director and Liz Najera, Executive Director. Today's visit was in response to an Unusual Incident/Injury Report (LIC624), which licensee self submitted to the CCLD San Diego Regional Office on 2/23/26. According to the report, on 2/19/26, Staff #1 (S1) incorrectly placed a medication in the wrong destruction box, and the following day the medication was no longer present and there was no record of it being properly discarded. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour, reviewed relevant records and interviewed staff. LPA observed the room where medications are kept which is locked and inaccessible to residents. Per staff interviews, S1 did discard of the medication in the appropriate place after the mistake, but did not log the proper discarding of the medication. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Irma Sterling and Liz Najera to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.