Incident investigation·March 10, 2026

At approximately 2:50 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Executive Director/Administrator, Heather Montgomery. The facility submitted one (1) Incident Report (IR) for Resident 1 (R1) for a medication error. On 3/1/2026, Medication Technician (staff member S1) missed administration of a medication for resident R1. The medication was prescribed to be given at 3:30 PM. The medication was given to resident R1 at approximately 6:21 PM, three (3) hours later than the prescribed time. Resident R1's emergency contact and resident R1's Primary Care Physician were notified. Resident R1 was monitored by the Director of Health Services and no adverse reactions were observed. The facility will be cited for this medication error. The facility took disciplinary action against staff member S1. Additionally, the facility conducted Medication policy training for all Medication Technicians (Med Techs) on 3/6/2026 and 3/10/2026. As the facility has already conducted Medication Policy Training for all Med Techs, the deficiency will be cleared during today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Montgomery. Signature on form confirms receipt of documents.