Incident investigation·December 30, 2021

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude an investigation that began on the visit of 2/26/21. LPA met with Brenda Chappell and stated the purpose of the visit. On 2/26/21, LPA inquired about an incident report received by Community Care Licensing (CCL) indicating that resident (R1) received medication that belonged to (R2) which indicates there was a medication error. During that visit, LPA was able to interview Staff 1 (S1) and Executive Director. S2 was interviewed on 2/27/21. LPA requested, received and reviewed a copy of the medication record for both (R1) and (R2) and a revised Incident Report (SIR), and Medication Training documentation for S1. S3 was interviewed today during this visit. Upon review of the training schedule, S1 received orientation, training/shadowing, and worked with 2 Medication Technicians from 2/2/21 - 3/3/21 with the exception of the days off work. Based on interviews, and documentation the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809D during this visit. If any of the cited deficiency is not corrected by the noted due dates; additional civil penalties may be assessed. The facility staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.