Facility Evaluation Report

On 3/17/2026, Licensing Program Analysts (LPAs) M. Medina and K. Brown conducted an unannounced Case Management visit regarding a self reported medication error that was received in Fresno Regional Office (RO) on 1/28/2026.

LPAs met with David Cervantes, Administrator during today's visit.

Per incident report received in Fresno Regional Office on 1/28/26, a medication error occurred on 1/23/2026, staff 1 (S1) administered medication to resident 1 (R1) which was prescribed to resident 2 (R2). R1 was administered Fluphenazine 5mg rather than the prescribed Quetiapine Fumarate 50mg.

Documentation provided during case management visit documents, R1's physician was notified via email on 1/23/2026 of medication error and staff 1 (S1) received medication training on 1/25/2026.

Deficiency cited on the attached 809-D in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8.

Exit interview conducted. A copy of report and appeal rights provided to Administrator.