Incident investigation·November 13, 2025

On 11/13/2025, Licensing Program Analyst (LPA) conducted an unannounced case management visit to follow- up on an incident that was reported by the facility. LPA met with Resident Coordinator, Madeline Tigno and explained the purpose of today's visit. On 11/10/2025, CCL received an unusual incident/injury report from the facility reporting an incident that occurred on 11/6/2025 in which staff #1 (S1) gave resident #1 (R1) medication that was intended for resident #2 (R2). During today visit, LPA interviewed S1 who stated that when she returned from her lunch break, R1 usually sits in the dining room so she would give R1 medication. However, on the day of the incident, she noticed R1 was not in the dining room so she asked staff to get R1 to the dining room while preparing medication for R2. When she was about to give R2's medication to R2, R1 came into the dining room and she got distracted so she gave R2's medication to R1. S1 acknowledged that she did not ensure it was the Right Resident and the Right Medication prior to giving the medication to R1. Based on training records, S1 was trained in September 2023, September 2024 and on 11/6/2025 on Medications/ Medication Errors/Narcotics and S1 stated that the training covered " The Six Rights" of medication administration. Based on interview, records review and observation, deficient is cite for this incident because the S1 was trained on " The Six Rights" of Medication Administration, however, it was not followed while giving medication to R1 resulting in R1 received medication that was intended for R2. Based on observation, record review, and interviews deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the Resident Coordinator; A copy is provided with appeal rights.