Incident investigation·January 29, 2026

On 01/29/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Kelly Ording, Administrator. LPA is conducting a case management visit to obtain more information regarding three incident reports for medication administration errors received by the Department: one received on 12/05/2025 for an incident that occurred on 11/28/2025 involving resident 1 (R1) and staff (S1), and two received on 12/31/2025 for incidents that occurred on 12/26/2025 -- involving Resident 2 (R2) and Staff 2 (S2) and the other involving Resident 3 (R3) and Staff 2 (S2). LPA conducted an interview with Administrator and obtained documents. Facility is being cited for missed medication administration doses (see LIC809-D). The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt of documents.