Facility Evaluation Report

On May 4, 2026, Licensing Program Analyst (LPA) Garlli Tat conducted a case management inspection for the purpose of following up on a self-reported incident report received by the Department on April 16, 2026 regarding a medication error involving Resident #1 (R1). LPA met with Executive Director (ED) Melinda Forney and Nurse Manager Sheila Weathers and discussed the purpose of the inspection.

The incident report states that on April 11, 2026, R1 received wrong medications, medication nurse notified Medicine Director who advised facility staff to monitor R1 and report any changes, R1 was monitored, and additional training was conducted to avoid future medication errors.

During today’s inspection, LPA conducted a health and safety check on R1, observed no health and safety issues, and observed R1 was in good health and good spirits. LPA inspected the medication room, observed it to be clean and organized, and observed no health and safety issues. LPA interviewed the Nurse Manager who confirmed the information in the incident report and provided the following information: the medication error involved R1 receiving four medications not intended for that resident; the error was made by Staff #1 (S1) who was in training at the time of the incident; the facility notified the doctor and observed R1; family was notified, there were no complications with R1 and the doctor did not recommend sending R1 to the hospital. LPA reviewed training records showing that S1 completed the in-service on April 14, 2026.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.