Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for the purpose of issuing a deficiency found during a complaint investigation. LPA met with the Assistant Administrator, Elid Duran, and informed the purpose of the visit.

During the complaint investigation 28-AS-20260629134922, staff acknowledged the medication error that occurred on 6/25/26 for Client #1 (C1). The incident was reported to Community Care Licensing and Regional Center. It was documented that staff accidentally administered C1’s next day bedtime medication cycle on 6/25/26. Staff administered C1’s medication and then assisted another client with a request. C1 returned to the medication area, and staff forgot and administered the next day’s bedtime medications. Afterwards, Staff immediately realized the mistake and informed the administrator. C1 was taken to the hospital for evaluation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1) are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with E. Duran. A copy of this report and appeal rights were provided.