Incident investigation·September 7, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assistant Health Services Director Sulema "Sue" Alvarez. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/15/2023). The LIC624 described a medication incident involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe and alert. LPA also reviewed pertinent care records and interviewed relevant staff. Based on evidence, circumstances, and context obtained through reviewed records and interviews, no deficiency was cited for the above incident. Also, no deficiency was observed during today’s site visit. However, LPA issued one (1) Technical Violation (TV) regarding reporting requirements. LPA also provided Technical Assistance (TA) to Licensee regarding a medication cart procedure. An exit interview was conducted with Alvarez, to whom a copy of this report, the LIC9201-TV, LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.