Facility Evaluation Report

On 10/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 09/29/25. LPA met with Staff, LVN, Tiffany Gibson and explained reason for visit.

Special Incident Report (LIC 624) submitted by facility on 10/03/25 to CCL stated that resident, R1 was given wrong medications by staff on 09/29/25 around 08.30AM . Incident report indicated that R1 was given medications, Hydralazine HCI Oral Tablet 50 MG -1tablet, Lisinopril 20 mg-1tablet,Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG -1 tablet, Pantoprazole Sodium Oral Tablet Delayed Release 40 MG -1tablet, Ranolazine ER Oral Tablet Extended Release 12 Hour 500 MG -1 tablet, Clopidogrel Bisulfate Oral Tablet 75 MG – 1tablet, Furosemide oral tablet 40 mg- 1tablet which were not prescribed by thier physician. Facility notified R1s physician and responsible party on 09/29/25 regarding medication error. LPA was notified by administrator that facility took appropriate action with staff regarding this incident per facility policy who was associated with this incident .

Based on incident report, staff interviews and medication record review from the facility, R1 was given these medications by mistake. It was determined that facility administered wrong medications to R1 which poses a immediate health and safety risks to residents in care.

Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 87465(a)(4) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today.

The report was reviewed, appeal rights and a copy of this report was left at the facility.