Incident investigation·September 17, 2025

On 9/17/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an incident that was reported to the Department via an Incident Report received on 8/18/2025. LPA Calandra was greeted by Preet Kaur, Executive Director and explained the purpose of the visit. Joni Tsukimura, Director of Assisted Living and Anne Tabin, LVN, Nurse Supervisor joined the visit later. During the visit, LPA conducted interviews. Based on interviews, S1 poured medications for R1 and R2 and gave R1's medication to R2. Poison control was contacted immediately and R2 was observed for any change in condition. R2 has remained stable since the incident occurred. LPA received a copy of the fax cover sheet during the visit. A Type A citation was provided for the medication error. A Type B citation was provided for not submitting a written report to the licensing agency within seven days of the occurrence. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. This report was reviewed with facility representatives and a copy of the report provided.