Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection at the facility today and met with staff. Administrator Lydia Sattiewhite arrived shortly thereafter and was explained the reason for the visit. The purpose of today's inspection is to follow up on a self-reported incident which occurred on 09/05/2025.

On 09/09/2025, the Regional Office received an Incident Report (IR), reporting that on 09/05/2025, Client 1 (C1) was given one (1) wrong medication by a staff member (S1). C1 should have been given 1 tablet of Gabapentin 800 mg but instead was given 1 tablet of Guanfacine Hydrochloride 2 mg. It was further reported that C1 was taken to the hospital for evaluation and or medical treatment, C1's home and poison control were notified, S1 received disciplinary actions, has been suspended from dispensing medication, and will be supervised for 3 months in the future when they begin to dispense medication.

On 09/09/2025, LPA Cortez contacted the facility to request additional information over the phone. Staff advised the LPA that C1 was doing well and had no reaction to the medication error, however was taken to the hospital due to safety precautions, doctor was not concerned and C1 was acting normal, no symptoms and doing well. During today's visit the LPA interviewed the Administrator, attempted to interview C1, and conducted a file review. Per the Administrator, C1 was given another clients medication in error, however the other client still received their correct medication as they got administer the last pill of the month from the bubble pack and called the pharmacy to obtain a refill. LPA verified bubble pack. C1 appeared well during today's visit.

The following deficiencies were cited (See LIC 809-D.) from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Report and appeal rights were provided.