Facility Evaluation Report

At approximately 12:30 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Executive Director (ED) Carla Lua. The facility submitted one (1) Incident Report (IR) for Resident 1 (R1) for a medication error.

On 3/8/2026, at approximately 1:30 PM during the afternoon medication pass, medications were being delivered to residents directly in their rooms. During this medication pass Medication Aid MA1 mistakenly gave medications intended for resident R2 to resident R1. Medication aide MA1 immediately realized their error and called emergency services and notified ED Lua. Resident R1 was transported to the Kaiser Permanent Emergency Department for evaluation. Resident R1 returned to the facility later the same day. Resident R1 suffered no adverse effects of the medications given to them in error. Resident R1's after visit summary stated they should skip taking a specific medication the following morning on 3/9/2026. The facility did inadvertently give the medication that was to be skipped to resident R1. Resident R1 suffered no adverse effects of not skipping the noted medication. The facility has immediately changed its procedures so that three (3) staff members are reviewing residents After Visit Summaries when residents are seen in Emergency Departments or seen by their primary care physicians.

The facility will be cited for this deficiency.

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

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.