Incident investigation·May 14, 2021

On 05/14/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced case management visit regarding a self reported incident that occurred on 05/09/2021. Due to the Shelter in Place set forth by the Governor on March 17, 2020, LPA was not able to conduct the visit in person. The visit was performed by telephone. LPA spoke with Administrator, Joe Farrish. During the phone call LPA spoke and reviewed incident with Administrator. Administrator confirmed that R1 was given R1's PM medications instead of AM medications in the morning. The error was discovered fifteen minutes later. The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report emailed.