Incident investigation·December 10, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. DW stated all these residents live in Independent Living unit.On 12/05/2025, the Department received 4 incident reports regarding resident R1, R2, R3 and another incident report regarding R1. On 12/02/2025, resident R1 was given wrong medication nurse (S1) found the mistake immediately. R1 was also given the correct medication. S1 wanted to assessed R1 to check if R1 was fine but R1 refused and stated he/she was fine upon incorrect administration. R1 allowed S1 to assess later. The facility notified R1' PCP, and follows PCP's instruction. The facility notified pharmacist who stated the medications that S1 gave to R1 had no interaction to each other. DW stated R1 is fine and still lives in independent living unit. After the incident, the facility provide the staff training to S1, nurses and Med Techs. DW stated this is the first time of the incident regarding S1 and R1. On 12/01/2025, resident R2 reported R2's jewelry was lost to staff. Around 2:00PM, R1 called police department and reported the incident. DW stated police officers came to the facility to interview staff and residents. On 12/03/2025, Housekeeper supervisor reported that resident R3 lost Diamond Omega Watch. DM stated police officers came to the facility to interview staff and residents. Continue on LIC809-C. Page 1 of 2.. On 12/03/2025, resident R1's fiduciary reported that someone outside may financial abuse R1. DW stated police officers conducted interview on 12/09/25. LPA interviewed DW, Housekeeper Supervisor, 3 residents, and 1 staff. LPA toured resident rooms. LPA obtained the staff training material, copies of the updates of the incidents, and the statement of staff. At this time, these cases are under review and the Department will conduct a follow visit if warranted. Exit interview was conducted with DW. The report was provided to DW for review. A copy of the report was provided to DW. Page 2 of 2..