Facility Evaluation Report
On 11/5/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Assistant Administrator.
The department received a incident reports of medication error incidents that occurred on 11/21/25, 12/1/25 and between 11/29/ 25- 12/1/25 involving errors for R1 R2 and R3. Staff involved in the errors S1, S2, S3, S4 ad S5.
LPA discussed the incidents with the Assistant Administrator who was aware of the circumstances in the incidents. The medication errors individually involved wrong dose, wrong med, wrong time and missed medication.
Medication errors have been an ongoing issue at this program. Previous plans of corrections have been instituted as agreed. However, given the frequency and varieties of ongoing incidents, additional measures were identified today.
As a result of today’s inspection, deficiencies were noted. Civil penalties for repeat citations were issued.
Report reviewed. Copy of report and appeal rights provided
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction