Facility Evaluation Report
Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced to conduct a case management visit regarding two separate incident reports received on 11/21/2025 and 11/14/2025 regarding medication errors made.
In both incidents which occurred on 11/20/2025 for resident R1 and 11/11/2025 for resident R2, R1 and R2 were given the wrong medication. Staff acted quickly, calling poison control and emergency services. Both residents involved had no ill effects from the error.
Although a medication error was made, it appears that the both staff reacted immediately to follow up and ensure the resident's safety. Both staff have been reassigned and given re-training on medications.
As a result of this visit, a deficiency is being cited on 9099- D page. Appeal rights given. Exit interview conducted.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction