Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - incident visit. LPA met with Assistant Administrator (AA), Armando Guba.

The purpose of the visit is to follow-up on an incident report received on 09/04/2025 for resident (R1) regarding a medication error that was found on 08/25/25.

Based on the incident report, on 08/14/25 R1's medication (M1) was increased from 200mg daily to 225mg daily. On 08/18/25, the new dose of 225mg medication arrived and was to be started. Due to confusion of the changes, the med change was not started until 08/25/25.

On 09/04/25, LPA Monter spoke with the Administrator (ADM), Mark Castillo regarding the medication error. Based on interview, it was stated that the facility staff was giving R1 the incorrect dose of 200mg instead of 225mg. The medroom staff noticed that the new medication change was not "activated" on their E-MAR (electronic medication administrator record).

On 09/22/25, LPA Kabariti interviewed staff (S1) and the AA and obtained records to include R1's e-MAR, centrally stored medication records, and medication list.