Incident investigation·March 2, 2022

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Almavia of San Rafael for the purpose of conducting a Case Management-Incident inspection. LPA met with Administrator, Angela Boucher-Tourin, and was granted access into the facility. CCL received an incident report reporting medication errors for 16 residents. The error occurred on February 13, 2022.16 residents were not administered medication as prescribed. The nurse that was responsible for medication passes was told not to return to the facility. Responsible parties for the 16 residents and prescribing doctors were notified of medication errors. LPA obtained copies of the medication training for all staff members. 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 to the Administrator.