Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted a case management visit per follow-up on Special Incident Reports (SIRs) dated 7/14/2026 submitted to the department on 7/14/2026. LPA met with the RN (Registered Nurse), Linda Loeung and LPA explained the purpose of the visit. LPA Konishi spoke with the Administrator, Hazel Gatan over phone and LPA explained the purpose of the visit.

It was revealed on the Special Incident Report (SIR) dated 7/14/2026 that on 7/3/2026, Client #1 (C1) was given Metoprolol Tartrate 25mg tab and the medication order includes a parameter to hold the medication if C1’s heart rate is below 60 beats per minute. On 7/3/2026, C1’s heart rate was documented as 48 beats per minute prior to administration. It is also revealed on the SIR dated 7/14/2026 that on 7/5/2026, Client #2 (C2) was given Midodrine HCL 10mg tab and the medication order includes a parameter to hold the medication if C2’s Systolic Blood Pressure (SBP) is greater than 110. On 7/5/2026, the C2l’s SBP was 118 prior to administration. LPA interviewed the Administrator over the phone and the Administrator confirmed stating that the medication errors occurred.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are indicated on the LIC809-D page.

Exit interview held, appeal rights, and a copy of the report were provided to the RN, Linda Loeung.