Incident investigation·April 3, 2025

Licensing Program Analysts (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with Assisted Living Administrator (AL) Chelsea Chanduloy and stated the purpose of the visit. On February 24, 2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on February 22, 2025. The incident report states, resident R1 was accidentally administered the wrong dose of medicine. Instead of Medication M1's 25mg tablet, a medication M2 50 mg tablet was given. On April 3, 2025, LPA interviewed AL. AL stated the medication error only occurred once. AL stated what occurred that day, resident R1 told staff that he/administered two larger tablets instead of two smaller tablets that afternoon. AL stated R1 was administered the wrong dosage. AL stated the very same day R1's doctor/ family was notified. AL stated staff was told observe the resident and check blood pressure. AL stated R1 did not have a change to his her status the same day and the following day. AL stated R1 continued on his/her regular routine, with no issues noted. AL stated staff S1 was given training. AL stated the health services coordinator went over R1's medications with staff S1 to ensure R1's medications are being administered as prescribed. LPA received copies of R1's training's. Page 1 out of 2. Based on a review of R1's physician's report dated, August 7, 2019, R1 cannot administer his/her own medications. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with Assisted Living Administrator Chelsea Chanduloy and a copy of this report was provided. Appeal rights were also provided. Page 2 Out of 2.