Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and met with Nathan Harper, Assistant Program Manager regarding a Case Management- Incident Report at approximately 10:00 AM on 01/22/2026.

The inspection is being conducted to review the incident report of 01/06/26. It was reported that staff reviewed the Medication Administration Record (MAR) on the morning of 01/06/26 and discovered that Client (C1) had been administered the wrong dosage of medication at the wrong time by Staff (S1) on 01/05/26 at 8:00 PM. Staff contacted the Pharmacist as well as Poison Control, Advice Nurse and PCP. C1 suffered no ill effects. Deficiency cited. (See 809-D).

Deficiencies cited from the California Code of Regulations (CCRs), Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.