Incident investigation·April 24, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 12:24PM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 04/17/2025 Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and Health and Services Director (HSD) Antonio “Tony” Nunez. Entrance interview conducted. On 04/17/2025, the Department received a verbal and written incident report stating that on 04/17/2025, Resident #1 (R1)’s PRN Benzonatate 200mg was left unattended by Staff #1 (S1) and Resident #2 (R2) self-administered the medication mistaking the medication for their own. The error was observed after R2 asked S1 to take R1’s medication to them since R2 took it instead. R2’s primary care physician was notified and R2 was placed under direct supervision for delayed effects. R2 was monitored for changes in condition, no significant changes were noted, and vitals were stable within normal limits. HSD Nunez conducted one-on-one trainings with S1 on proper medication storage and administration protocols. Staff were also reminded to never leave medications unattended. All staff attended a training session vendored by Guardian Pharmacy on 04/07/2025. HSD stated that a corrective action form was issued to S1 and that each medication technician will be shadowed for a full day and tested on proper protocols and regulations. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was assessed in the amount of $250. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided. This report has been amended to include a civil penalty of $250 due to repeat violation of Section 87465(h)(4) as it has been cited one other time within 12 months on 03/11/2025.