Incident investigation·March 2, 2022

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Drake Terrace for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA was met by Administrator, Ricardo Romero, and was granted access into the facility. CCL received an incident report reporting a medication error. The error occurred on 02/15/2022 while trainee was dispensing medication. R1 was given the wrong prescribed medication during medication passing. R1 and R2 were sitting together and both had the same first name, medication error was observed on 2/15/2022 by S1. Responsible party and prescribing doctor were notified of medication error. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of February 2022 for R1. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.