Facility Evaluation Report
On 12/18/2025 at 9:55 a.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding medication related incident reports received by the Community Care Licensing Division (CCLD) on 12/09/2025, 11/20/2025, 10/20/2025 and 07/03/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr and explained the purpose of the visit.
The case management visit was conducted due to multiple Unusual Incident Reports (UIRs) submitted by the facility over several months involving medication administration errors.
CCLD received a UIR regarding an incident that occurred on 12/07/2025, which indicated that Resident (R1) requested a PRN medication for agitation; however, Staff (S1) administered an anti-diarrheal medication instead to R1.
CCLD also received a UIR for an incident that occurred on 11/19/2025 at approximately 5:00 p.m., which indicated that R2 was inadvertently administered the wrong medication during the evening medication pass by S4 and S5. During interviews with S2 and S3, it was stated that the medication error occurred while S5 was training S4.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction