Incident investigation·July 8, 2025

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Mona Kaur, Executive Director, to discuss the purpose of the visit. Today's visit is in response to two self reported incidents. On 4/30/2025 the facility reported a medication error by Staff 1 (S1) where a medication was accidentally administered twice. The facility conducted an internal investigation which confirmed the medication error. The Medication Technician (Med Tech) involved was re-trained regarding medication administration protocols. On 06/17/2025 the facility reported an accusation of missing money for Resident 1 (R1). The facility conducted an internal investigation which included interviews with R1, the staff member accused, staff statements, interviews with R1's family, and review of exterior camera footage during the alleged timeframe of the incident. The facility's internal investigation was inconclusive and did not give evidence that the staff member removed money from the resident's purse. The investigation further revealed inconsistencies regarding the details of the event. The resident's family informed that the last time they observed the money in question was at the resident's prior facility, not this facility. LPA conducted a wellness check at the facility; no health or safety issues were identified. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).  A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Mona Kaur, Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.