Incident investigation·May 19, 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 a medication error. LPA met with Executive Director Kim Humphrey and Resident Services Coordinator Dylan Nunn and reviewed records. Resident was given the wrong dose of medication. Staff verified the order for the medication but did not verify the name on the medication. Resident was given another residents medication, although is was the same type of medication it was the wrong dose. Facility conducted an investigation and conducted retraining for the staff. This is a repeat violation of the same section in a 12 month period. A civil penalty is being issued in the amount of $250.00. 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 Kim Humphrey and Appeal rights were given.