Facility Evaluation Report
On 11/18/2025, Licensing Program Analysts (LPAs) Graham Gunby and Cheyenne Ratacjzak arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 11/03/2025 for resident for medication error as reported by facility on 11/14/2025 by Incident Report ( LIC624). LPAs met with Executive Director, Keith Payne, and explained the reason for visit.
On 11/03/2025 the p.m. med tech called off and the NOC med tech was called in early to pass medications. The NOC mtd Tech missed the window to pass medication and let staff know hours later. This communication error led to 24 residents missing their p.m. medication.
As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed. Copy of report and appeal rights provided
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction