Complaint·April 24, 2026

GM states R1's was given another resident's medication in error by S1 on 4/14/2026. GM states all responsible parties were notified of the incident on 4/14/2026. GM states R1 was monitored for possible side effects. GM states R1 did not have any side effects during this incident. On 4/24/2026 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 staff state he/she is aware of the medication error that occurred on 4/14/2026 where S1 gave R1 another resident's medication. S1 states he/she assessed R1 on 4/15/2026, taking R1's vitals, which were 'normal.' S1 states he/she also called R1's family regarding the incident. On 4/20/2026 the Department received an incident report of the medication error for R1. The incident report states "Medication error noted: resident administered 2 medications in error. contacted after hours MD emergency line...advised to observe resident...POA and HSD notified via phone...care conference held with resident's POA on 4/16/2026." Review of R1's physician's report dated 10/5/2023, R1 has neurocognitive impairment and cannot administered his/her own medications. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated . California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin and a copy of this report and appeals rights were provided. Page 2 of 2 END OF REPORT