Incident investigation·August 13, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self-reported Unusual Incident/Injury Report (UIR) received. LPA met with Executive Director Christian Castillo and explained the reason for the inspection. On 08/13/2025, Community Care Licensing (CCL) received a self-reported Unusual Incident/Injury Report (UIR) pertaining to missed medications that occurred on 08/05/2025, and 08/06/2025 regarding Resident #1 (R1). It was reported that on the morning of 08/05/25 and and 08/06/25 R1 did not received their prescribed dose of Synthroid 50 mcg. R1 has two seperate orders for their medication depending on the day of the week, R1 received a new order changing the days, and when updating the EMAR, Staff 1 (S1) mistakenly discontinued the old order without approving the new one. It was reported, R1's POA and PCP were notified and S1 received medication training on 08/12/25. During today's visit, the LPA interview the Executive Director, who stated R1 is doing fine, and there were no symptoms or reactions to the missed medications. The following deficiency was cited from the California Code of Regulations, Title 22 and California Health and Safety Code. (See LIC 809-D) Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.