Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso. LPA is conducting a case management - incident inspection, on 1/14/2026, and met with Edward Bechtel, Resident Supervisor. Administrator Catherine Brenegan arrived shortly after being notified by staff of LPA's arrival.

LPA reviewed client files, C1 & C2. LPA reviewed a recent client incident report regarding a client taking another client's medications.

C1 grabbed a spoonful of some pudding mixed with some of C2's medication in it, and ingested it. Staff contacted Kaiser Advice Nurse regarding the medication error. Staff were instructed to monitor C1, and if any observed behaviors that are not their baseline, call 911 and have the client seen by medical professional. In review of C2's records, there was no Dr's Order for C2's medications to be crushed and taken by the client.

Per review of the incident, C1 was able to gain access to medications that were not prescribed to them, by their Physician, and ingest them. C2 did not have the required Dr's Order for staff to crush medications, and provide them to the client.

The above deficiencies will be cited, 80075(b) Health Related Services - Clients shall be assisted as needed with self-administration of prescription and nonprescription medications;

80075(b)(3) Health Related Services - Assistance with self-administration does not include hiding or camouflaging medications in other substances without the client's knowledge and consent, or otherwise infringing upon a client's right to refuse to take a medication, see LIC809D.

The following deficiency(s) were 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 with the Administrator Catherine Brenegan. Appeal rights provided.