Incident investigation·April 23, 2026

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management - incident visit. LPA met with General Manager (GM) JP Rollet. LPA stated the purpose of the visit. Medication Error 7/25/2025 The purpose of the visit was to address 2 medication errors that occurred on 7/25/2025 and 4/16/2026. On 7/30/2025, the Department received an incident report regarding a medication error on 07/25/2025 involving Staff S1 giving resident R1 another resident's medication. The incident report states S1 "accidentally gave the medication to another resident." S1 reported the medication error to management, and 911 was called. R1 was taken for observation to the hospital, and returned back to the facility the same day with no injuries. The reports states R1 was monitored by staff for changes in condition after the medication error, and R1's family and primary care physician were notified. On 9/19/2025, a Case Management visit was conducted. During visit, LPA requested copies of the following documents: Disciplinary Notice, In-Service Training Records, physician's reports, Service Plans, Centrally Stored Medication and Destruction Records, and Medication Administration Records (MAR). Medication Error 4/16/2026 On 4/21/2026 the Department received an incident report regarding a medication error on 4/16/2026, involving Staff S2 giving Resident R2, an incorrect dose of medication. Page 1 of 2 The incident report states "Wellness nurse administered the medication but immediately realized that a double dose of the medication was administered. Wellness Nurse admitted to not completely reading the medication order thereby committing the mistake." The incident report notes R2 was observed, vitals were taken and R2 monitored for side effects. During today's visit, LPA interviewed 3 Staff (S1 to S3), 2 Residents (R1 to R2), and 1 Witness (W1). Based on investigation on 4/23/2026, S1 and S2 reported the medication errors to facility management when the errors occurred. Documents were obtained to include S1 and S2 training records, S1 and S2's written disciplinary action, and R1 and R2 physician's reports and care plans. LPA Tarin also conducted a safety check on R1 and R2. LPA observed R1 watching tv in his/her room. R1 did not respond to LPA's questions due to cognitive impairment. LPA observed R2 sleeping in his/her room. LPA observed R2 had a private companion. A civil penalty is being assessed for the amount of $250 for a repeat violation for CCR 8 7411(a) . A previous licensing report issued on 3/16/2026 cited the same deficiency. Please see LIC421FC. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. A Deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. An exit interview was conducted with GM JP Rollet and a copy of the report and appeal rights were provided.