Facility Evaluation Report
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management to follow up on a incident report regarding a medication error. LPA Valerio met with licensee Rochelle Cister and administrator Florinda Fuentes.
On 11/05/2025 Administrator Florinda Fuentes was conducting a medication audit and discovered Resident 1 (R1) medication bubble pack was inside of Resident 2 (R2) medication bucket. It was learned that facility AM staff (S1) gave R2 R1's AM medication for 11/05/2025. Facility staff immediately went to pick up R2 from day program and took R2 to the emergency room. No side effects or concerns were noted from the physician. R2 was monitored for the rest of the evening with no noted concerns.
The facility conducted an all staff medication training on 11/08/2025. LPA Valerio observed this to be completed. LPA also observed additional medication training held for staff on 11/10, 11/11, 11/13, and 11/20. Plan of Correction has been cleared during today's visit.
Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited today on the attached LIC 809- D page. An exit interview was held, and a copy of the report was provided. Appeal rights provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction