Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error and a incident report regarding an elopement. LPA met with Administrator Jasmine Latu and stated the purpose of the visit.

On January 5, 2026 the Department received an Incident Report for a medication error of Resident R1 that occurred on January 2, 2026. The incident report states: on January 2, 2026, at approximately 5:21pm, a medtech noticed he/she gave R1, resident R2’s medication M1. The Med tech realized the error and contacted the regional nurse and executive director. Medtech contacted R1's physician and POA.

On January 5, 2026 LPA Manuel Monter spoke to Administrator (ADM) Jasmine Latu. ADM stated the medtech made a mistake giving R2's meds to R1, because both of these residents have the same initials. ADM stated the medtech realized the mistake and informed the residents POA and physician. ADM stated the staff member has been retrained.

The Department reviewed R1’s Physician’s Report dated September 19, 2025. The physician’s report states R1 is not able to administer his/her own medications and is not able to store his/her own medications.

The Department reviewed R1’s ally comprehensive evaluation, dated December 11, 2025. Under medication, the form states, “staff will help the resident with taking their medication.”