Incident investigation·March 8, 2022

On 03/08/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management inspection at the above facility. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Sarah Dennis. The purpose of today’s visit is to follow up on an Incident Report that was submitted to the Fresno CCL office on 02/23/2022. It was reported that on 02/23/2022 at approximately 09:15AM, S1 “pulled medications for R1, however, S1 administered the medications to R2. Per Administrator, S1 went to retrieve R1’s medication from the med room, R1 attempted to follow the nurse and ended up leaving the area. R2 sat in the chair were R1 was previously sitting. When S1 returned, S1 gave R1’s medications to R2. Based on interviews and records review, a deficiency is being cited on the attached 809D in accordance with the California Code of Regulations, Title 22, Division 6. An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and Appeal Rights will be provided to Administrator via email due to COVID-19 precautionary measures. Report signed on-site by Facility Representative.