Incident investigation·November 19, 2021

Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to follow up on incident reports received on November 4, 2021 and November 12, 2021. LPA Ryan introduced herself, stated the purpose of the visit, was allowed entry, and met with Executive Director, Sheryl Johnston Community Care Licensing (CCL) received incident reports regarding Resident 1 (R1) and Resident 2 (R2) experiencing medication errors on separate occasions at the facility. The facility self-reported these incidents to CCL. During the visit, a medication error regarding Resident 3 (R3) was also reported. During today's visit, LPA toured the facility, reviewed resident records, and interviewed staff and residents. A deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted with Sheryl Johnston and Joan Gomez. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the executive director at the conclusion of the visit, an electronic response confirms the receipt of these documents.