Incident investigation·July 21, 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 Executive Director Thomas "Ozz" Daynes. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 06/20/2023). According to the LIC624, on 06/16/2023, an error by Staff #1 (S1) led to Resident #1 (R1) being given and ingesting doses of two (2) medications which were not prescribed to them. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. These unauthorized doses did not result in R1 experiencing adverse symptoms. During today’s visit, LPA performed a brief facility tour and welfare check, finding that R1 was safe, alert, and talkative. LPA reviewed pertinent records and interviewed R1 and relevant staff. LPA also sat in as an observer for a portion of the facility’s Resident’s Council Meeting. Interviews and records showed: R1 required staff assistance with storing and taking their prescribed medications. The above medication errors were timely reported via phone to R1’s physician and R1’s responsible person. Licensee followed the physician’s instructions (i.e., to keep observing R1 and measuring their vital signs). Licensee increased observation of R1 over the next 72 hours. R1 did not present any adverse symptoms during that time. Following the incident, Licensee: a) individually counseled and retrained S1 on accurate medication pass procedures, and b) retrained their larger medication technician team on accurate medication pass procedures. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] A preponderance of evidence exists showing that during the incident in question, Licensee did not assist R1 with medications as prescribed by R1's doctor. One (1) deficiency is thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation regarding Reporting Requirements (refer to the attached LIC 9102-TV). An exit interview was conducted with Daynes, to whom a copy of this report, the LIC 809-D, the LIC 9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.