Facility Evaluation Report

At approximately 11:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Administrator, Matthew Long. The facility submitted one (1) Incident Report (IR) for Client 1 (C1) for a medication error.

The IR stated that on Monday, 9/1/2025 C1 self administered AM medications prescribed for Client 2 (C2). Both Client C1 and Client C2 take the same medication but in different doses. Client C1 was given the incorrect medication by staff member S1. Client C1 was taken to an urgent care facility as a precautionary measure. Staff member S1 mistakenly gave Client C1 Medication meant for Client C2. Client C1 did experience mild side effects from the medication error. Administrator Long stated that Client C1 was back to baseline condition twenty-four (24) hours after the incident and that there have been no residual side effects. Client C1 has a precautionary follow-up appointment scheduled with their primary care physician.

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 Administrator Long. Signature on form confirms receipt of documents