Incident investigation·October 2, 2023

At approximately 11:15AM, 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 08/21/2023. LPA met with Business Office Manager Eugene Pascual. The details of the incident report was a report of a medication error that occurred on 08/15/2023. Medication technician on duty signed off that they had administered the medication, but the pill was found to still be in the package. Interviews conducted by the facility with the medication technician found that during the medication pass, staff became distracted and might have taken the pill from a different residents supply, or signed that the pill was given without actually doing so. Staff was provided retraining in the administration of medication and has completed a review of facility procedures. LPA received copies of completed training verification. 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 Eugene Pascual and Appeal rights were given.