Facility Evaluation Report

At approximately 1:30PM, Licensing Program Analysts (LPAs) Felias and Contreras arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Mary Jane Miranda. The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL).

Incident Report 1 : On 02/18/2025, CCL received an incident report. Per report, on 02/11/2025, Resident 1 (R1) was administered a medication that was for Resident 2 (R2). Report stated that facility monitored R1 for adverse effects. R1 was found to be in good health. Facility made all appropriate notifications per regulation.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.