Follow-up on corrections·August 15, 2025

Licensing Program Analysts (LPAs) Nacole Patterson, Ramin Hashemi, and Janet Ngallo conducted an unannounced case management visit. LPAs identified themselves and met with Executive Director Mona Kaur and Assisted Living Director Michelle England to discuss the purpose of the visit. Today's visit was in response to a self-reported medication error that occurred on 07/28/2025. Staff interviews and records review showed that the Resident 1 (R1) did not experience any injuries or adverse reactions due to receiving two doses of a routine medication. The facility conducted an internal investigation which revealed that two Medication Technicians (Med Techs) were administering medications to the same floor during the incident, and the extra dose was given to R1 due to a communication error between the Med Techs. The facility contacted R1's responsible party and primary care physician regarding the error, and notified the Department per requirements. This is the facility's second medication error within a 12-month period. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Repeat Civil Penalty totaling $250 was assessed/charged to Licensee (refer to the LIC421-FC page). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Mona Kaur, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.