Incident investigation·November 29, 2022

Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit regarding a self reported medication error that was received in Fresno Regional Office (RO) on 11/23/22. LPA met with Jenny Lambarte, Residential Services Manager during today's visit. Per report received in Fresno RO on 11/22/22, R1 received the incorrect dosage of medication. R1's physician orders were changed on 11/18/22, R1’s current medication dosage was increased. Facility received new medication delivery on 11/21/22 however failed to discontinue R1’s old prescription resulting in R1 receiving both dosages. R1’s physician was contacted and no additional medical treatment required. R1's conservator also notified by e-mail. LPA informed that staff will receive mandatory medication training on 11/30/22. LPA received copies of Physician report, physician orders, MARS, and e-mail to responsible party, Deficiency cited on the attached 809D Exit interview conducted. Appeal rights given.