Incident investigation·July 9, 2025

On 07/09/2025, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to meet with Karrie Silvey (KS), Executive Director, regarding a Case Management- Incident Report. The inspection is being conducted to review incident report of 06/08/2025 where resident (R1) took a pill found on the floor of their apartment. R1 reported their actions to staff. As the pill could not safely be identified EMTs were called and R1 was transported to hospital for observation. R1 was evaluated and returned to facility same day. LPA conducted an incident report review of the resident medication error with KS. KS reported that the facility has conducted re-training with medication technicians with the Six Rights of the Medication Administration to ensure medications are administered correctly. Per conferencing with administration the licensee will ensure that clients are administered medication properly. (See 809-D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 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.