Incident investigation·October 3, 2024

On 10/3/2024 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 9/19/2024. LPA met with Executive Director, Ric Pielstick and informed him the reason for the visit. LPA later met with Health Service Director, Maria Tejano. Based on the incident report received on 9/19/2024, resident (R1) was given the incorrect medications. Facility staff immediately monitored R1 for any adverse drug reactions and vital signs were obtained. R1's family and doctor was immediately notified. During visit, LPA interview 3 staff and reviewed R1's file including physician's report, medication list, care notes, incident report, and training information. Care notes stated that R1 did not have adverse drug interaction during incident. LPA observed staff (S3) had online medication training. However, facility was not able to provide hands on shadowing training documents during visit. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Maria Tejano. A copy of this report and appeal rights provided.