Facility Evaluation Report

At approximately 1:45 PM Licensing Program Analyst (LPA) arrived unannounced on a case management visit related to a self-reported Incident report received by Community Care Licensing on 04/14/2026 and met with Administrator Peter Kori. LPA notes that Community Care Licensing (CCL) had also received an earlier call from Administrator Peter Kori on 04/12/2026 to report the incident.

The incident report stated that on 04/12/2026 on the PM shift, staff (S1) accidentally administered client (C1) a double dose when a PM dose was given and then a PM dose of the same medicine to be dosed out the next night was also given to C1. Report of the error was reported to client (C1's) family, Physician, Poison control, Residential Service Provider, as well as, the North Bay Regional Center.

Distraction of S1 by C2 was cited by the facility as the reason for the error. An audit by staff (S3) discovered the error and alerted the administrator, the house nurse and the facility sought the advice of poison control and C1 had their vitals checked every 30 minutes and fluids were encouraged by report for the remainder of the PM shift and then hourly on NOC shift with C1 noted to eat 100% of their breakfast, ambulating normally and not seeming to suffer any adverse effects. Facility is noted to have a similar medication error on 11/22/25 with distraction of caregiver cited as the reason.

During today’s Case Management visit, LPA conducted an interview, made observations and obtained documents.