Follow-up on corrections·July 13, 2023

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Kyle Ruth-Islas & Jill Ciambriello, Social Worker. LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 07/6/2023 of a medication error. The error occurred on 7/5/2023 at the nurse’s station. Resident (R1) came to station for medication, while R2 came into the office with Med Tech. Med Tech handed the agency nurse on duty medication for resident R2 and the nurse mistakenly gave it to R1. (See LIC809-D). All appropriate parties and prescribing physician were notified of the medication error. R1 was sent to hospital overnight for observation. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of July 2023 for R1 that reflects the said medication error. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..