Follow-up on corrections·October 5, 2023

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/5/23 at 10am to conduct an investigation of a medication error. LPA met with Bailey Leach, Business Office Director and stated the purpose of the visit. Community Care Licensing (CCL) received an Unusual Incident/Injury Report incident report (LIC624-SIR) dated 9/15/23 regarding resident #1 (R1). The SIR indicated that on 9/12/23, R1 received medication that should have been administered at 11:30am but instead it was administered at 2pm. R1 should have received eye drops during the 2pm medication pass but did not receive that. In essence, Staff #1 (S1) inadvertently switched the medications and times that should have been administered. The responsible parties of R1 and S2, was present with R1 at the time when the medications were questioned by S2. S2 contacted the doctor and placed R1 on 72hr alert charting. There were no adverse reactions to the medication error. S1 was removed from the Medication Technician position and will be re-trained with shadowing. LPA interviewed S1-S3, R1, and responsible parties of R1. Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview conducted and a copy of todays’ report provided.