Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility designee. Administrator (Admin) Guadalupe Garcia was present. Admin certificate 7030880740 expires 5/4/27.

On 5/4/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 5/1/26, at approximately 8:45pm R1 was administered one (1) tab of 1mg Benztropine instead of the prescribed two (2) tabs of 1mg Benztropine on 4/29/26 and 4/30/26 ( deficiency cited, see 809D ). R1 was monitored for adverse reaction and was observed to have no adverse reactions. All required partied were notified. Per Redwood Family Care Network District Manager (DM), Arneatha Simon, the error was observed when the medication bubble pack was reviewed on 5/1/26. Per DM, staff were trained on medication management on 5/4/26. LPA reviewed training records. Additionally, staff responsible for error are to receive disciplinary action, actions are pending corporate review and will be administered within 7 days.

On 5/14/26 CCL received an Incident Report indicating a medication error for resident (R2). On 5/12/26, during a medication audit, it was discovered that R2 did not have a doctor's order on file for their Omeprazole 20mg, given twice daily ( deficiency cited, see 809D ). Per DM, it was determined that R2 arrived at the facility with the medication and a MAR was created for administration. There was record of a request for a formal order from the treating physician with no response. Rene Litzenberg, RN, requested the doctor order on 5/12/26, and DM sent a second request via the KP.org communication portal on 5/13/26. There was no response by the treating physician at the end of the business day. At approximately 7:00pm on 5/13/26 R2 was taken to Kaiser to determine if the medication needed to continue to be administered. R2 returned to the facility at approximately 10:30pm with a doctor order to administer Omeprazole 20mg twice daily.