Incident investigation·March 27, 2026

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management inspection and met with Executive Director (ED) Kristine Soriano/Hiquiana. The purpose of today's inspection was to follow up on self reported incidents submitted to Community Care Licensing (CCL) on 03/24/2026. LPA made observations, conducted interviews and obtained copies of resident records pertaining to medication error. On 03/14/2026 at approximately 0930, S1 was at the medication cart preparing meds for a resident. Resident (R1) approached the medication cart and requested their medications. S1 mistook R1 for the resident they were preparing meds for and handed R1 the other resident's medications. S2 observed the mistake and notified the ED, R1's doctor (PCP), Nursing Consultant and the responsible party immediately. Nursing Consultant advised R1 be monitored for any reactions or change in baseline. R1's vital signs were monitored. R1 had no adverse affects to this incident. On 03/21/2026 S2 was assisting R2, when S2 noticed that R2 had an empty medication cup with the room number of another resident. R2 had received the wrong medications by S1. S2 notified the supervisor on duty, R2's doctor, Nursing Consultant and R2's responsible party. R2 was placed under observation and close monitoring for any reactions. R2 remained at baseline. R2 had no adverse affects to this incident. Continued on 809-C Continued from 809.... LPA discussed re-training and shadowing of medication technicians. Copies of relevant records were obtained by LPA. Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.