Facility Evaluation Report
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Jonafe Buenaventura, staff.
The purpose of the visit was to follow up with an Unusual Incident/Injury Report (IR) that the facility submitted to the department on 03/24/2026. The IR stated that on 03/23/2026, staff S1 gave resident R1 five dosages of medication belonging to another resident. S1 called 911 for R1 and paramedics transported R1 to the hospital for monitoring.
During visit, LPA Marrufo obtained a copy of S1's Corrective Action Form, dated 04/27/2026. The Corrective Action Form stated that S1 mistakenly administered five dosages of another resident's medication to R1. The form states S1 must follow the "Triple-check" system of medication administration and prepare medications individually for each resident.
An Advisory Note was issued. See LIC9102 for more information.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with staff Jonafe Buenaventura and a copy of this report was provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction