Incident investigation·June 21, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 06/10/2022. LPA met with Executive Director Rosa Ayala and explained the reason for the visit. Incident report dated 06/07/2022 indicated that Staff 1 (S1) had administered Resident 1's (R1) medication to R2. R2 was administered Lasix 20 mg, Lutein 20 mg, Metropolol 12.5 mg, and Xarelto 20 mg. Resident is not prescribed any of those medications. R1 did not receive any medications. Physician and family notified and facility staff monitored R2 hourly including vital signs. No adverse effects noted. Facility investigation revealed S1 was hired on 05/26/2022 and was shadowing another staff. S1 inadvertently gave the medications to the wrong resident. Medication administration record was signed incorrectly indicating both residents had received their medications. S1 received corrective action. LPA reviewed medication training for S1.S1 had completed 16 hours of shadowing prior to incident as well as computerized medication training. During the visit, LPA observed both residents in the facility. R1 was participating in activities and R2 was relaxing in the resident's room. Both residents appeared safe and well taken care of. Based on the observations and interviews made, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with Executive Director.