Incident investigation·August 27, 2024

At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management in regards to an incident report submitted to the department on 08/26/2024. LPA met with Executive Director Dorla Licausi and reviewed records. On 08/17/2024, Resident, R1, received a wrong dose of medication. After R1 had already taken the pills, staff noticed it was the incorrect amount of medication. Physician was notified and informed staff to observe resident for changes. The amount of this medication has been changed several times in the past few months and the medication was not flagged when the dose changed the last time. Staff was retrained on facility medication practices to ensure an error does not occur in the future. ***This is a repeat violation of the same code section in a 12 month period. An immediate Civil penalty is being issued in the amount of $250.*** 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 Dorla Licausi and Appeal rights were given.