Incident investigation·March 18, 2026

Licensing Program Analyst (LPA)Janet Ngallo conducted an unannounced case management visit. LPA identified herself and met with Catherine Tomboc Director of Resident Care, to discuss the purpose of the visit. Today's visit was in response to the self-reported incident reports. The incident reports dated 12/20/2025, 01/17/2026, and 03/09/2026, all involved medication errors. The incident reports received by the Department indicated that, in each of the three events, the residents involved were administered a second dose of the same prescribed medication within the same day.  Per the reports, the initial medication administrations were not documented in the facility’s medication administration record (MAR). Per staff interviews, no adverse reactions were observed or reported in any of the residents involved. One(1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D page). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Catherine Tomboc, Director of Resident Care, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.