Incident investigation·March 18, 2026

Licensing Program Analyst (LPA)Janet Ngallo conducted an unannounced case management visit. LPA identified herself and met with Executive Director Meg Franz, to discuss the purpose of the visit. Today's visit was in response to the self-reported medication error that occurred on 02/13/2026. LPA conducted interviews, made observations, and reviewed pertinent records. Interviews revealed that on 02/13/2026, Resident 1(R1) was given the wrong medication. Staff 1 (S1) administered to R1 the medication intended for the resident in the adjacent room . Interviews revealed the error was caught immediately, staff called emergency services, and R1 was transferred to the hospital for evaluation and treatment. No adverse reactions occurred in R1. 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 Executive Director Meg Franz and a copy of this report, the LIC 9099-D page, along with the Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.