Facility Evaluation Report

On July 8, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Taylor Simerly made an unannounced visit to the facility to conduct a Case Management - Incident inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Dee Navarro was present and assisted on today's visit.

LPAs are conducting the visit to follow up on a self reported Unusual Incident/Injury Report (UIIR) that was submitted to the Orange County Regional Office on July 2, 2026. The UIIR described that Resident #1 (R1) was given the incorrect dosage of her prescribed Tolvaptan 15 MG tablet routine medication on June 28, June 29, and June 30, 2026. During today's visit, LPAs reviewed and collected pertinent documents such as R1's identification sheet, medical assessment, active medication orders, and medication administration records. LPAs conducted an interview with R1, however, R1 was unable to provide any information regarding the incident. LPAs also conducted two staff interviews. Both staff interviewed confirmed that the UIIR submitted to the Orange County Regional Office was correct and that a medication error did occur with R1 on three separate occasions in June 2026. LPAs also reviewed the medication administration records for R1 for July 2026 and observed that R1 was also given the incorrect dosage of her prescribed Tolvaptan 15 MG tablet routine medication on July 1, 2026.

Based on the information gathered during the visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Executive Director Dee Navarro. A copy of the report and appeal rights were provided at time of visit.