Incident investigation·April 23, 2026

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident visit. Upon arrival LPA met with Cristina Williams and explained the reason for the visit. On 04/06/2026 and 04/17/2026  the Department received two (2) separate self reported incident reports for missed medications for Client #1 (C1) and Client #2 (C2). On 04/02/2026, it was discovered C1's evening dosage of Lorazapam for 04/01/2026 was not administered. On 04/15/2026, it was discovered C2's afternoon dosage of Olanzapine was not administered on 04/14/2026.  No side effects or concerns were reported for each instances.  Two (2) staff were retrained and are back to passing medications. At approx 11:26 p.m. LPA conducted physical plant, interviewed staff as well as  reviewed and obtained copies of pertinent documentation relevant to the incident. The Administrator stated that they will continue to follow their protocol requiring one medication passer to observe another during medication administration to ensure proper oversight. In addition, the Administrator will require medication passers to wear a brightly colored vest to signal to other staff that they should not be interrupted, allowing them to focus on administering medications safely. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeals rights discussed and copy of report issued.