Incident investigation·September 25, 2024

On September 25, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced for a Case Management visit. LPA met with Sita, executive director, and informed her the reason for the visit. On August 8, 2024, Sita admitted a resident that came from a skilled nursing facility. That resident came to the facility with medication (narcotics). A second medication was mailed to the facility as well August 7. On August 31, 2024, Sita found medications outside the medication room, which was missing 30 pills out of 60 pills. Sita conducted an investigation and discovered a staff that had been employed with her for 4 years knew the most about the medication and signed for them when they arrived, but did not log them in. The next day 30 of those pills were missing. Sita terminated the staff's employment due to not following proper procedures and not reporting the incident to her when It happened. Sita filed a police report with Sacramento County Police. LPA reviewed the report. No citations were issued. An exit interview was conducted and a copy of this report was given to Sita.