Facility Evaluation Report

Licensing Program Analysts (LPAs) Deniz & Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a self reported medication error. LPAs met with Business Office Director, Tony Ibarra , Administrator Morgan Whinery was unavailable.

LPAs are following up regarding a self reported Incident Report received by Community Care Licensing (CCL) on 5/27/2025 of a medication error. The error occurred on 5/16/2025 while med tech was dispensing medication. Medication technician inadvertently provided resident (R1) oral antibiotics instead of doctors prescribing order of topical antibiotic, Regulation 87465(a)(4). (See LIC809-D). Hospice, family, and primary care physician contacted. R1 was monitored with no signs of adverse reaction. LPAs obtained internal investigation, medical assessment, care plan, EMAR & care notes, and corrective action.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided