Incident investigation·June 6, 2024

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on a self-reported incident regarding stolen medication. The incident report was received by Community Care Licensing (CCL) on April 29, 2024. LPA was greeted and allowed entrance into the facility by Administrator (AD) Itzayana Barba Aguirre. LPA explained the reason for the visit. LPA conducted a toured of the inside and outside of the facility as well as bedroom of Resident 1 (R1). Incident report dated April 26, 2024 states that on April 22, 2024 R1 missed a dose of their medication due to another resident taking their bubble pack. During today's visit LPA reviewed documents including the Citrus Hills Assisted Living In-Service trainings dated April 22, 2024 and April 25, 2024 on how to lock and unlock the medication cart/how to ensure medication carts are locked/what to do if a narcotic count is off. Per AD the facility has also implemented a Plan of Action to prevent medications from being stolen in the future. AD reported that the Plan of Action will include that the Medication Technician (MT) keeps the keys with them at all times, the MT will double check that the medication cart is locked before stepping away and the MT will do a medication count at the end of every shift. During' today's visit LPA observed the MT passing out medication. LPA observed as the MT locked the medication cart before stepping away. An exit interview was conducted with AD Barba and a copy of this report was provided at the time of this visit.