Incident investigation·October 25, 2022

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted to CCL on 10/24/2022. LPA met with Administrator Almida Ayala, reviewed records and interviewed staff. The incident was in regards to a medication error occurring on 10/22 and 10/23/2022. Client, C1, was prescribed an antibiotic to be taken for five days starting 10/20/2022. When staff were preparing medication on 10/24/2022, it was noticed there were three pills remaining, when there should have been only one. An investigation was conducted and found that the medication was missed because it was not in the normal bubble pack. Staff will be retrained on the medication administration procedures of the facility. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Almida Ayala and Appeal rights were given.