Incident investigation·April 28, 2023

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility. LPA met with Jennifer Farley, Program Director and Enedelia Avila, Staff in Charge (SIC). The purpose of today’s visit is to address two self-reported incidents reported to CCL on 4/12/2023 and 4/25/2023. Incident #1: CCL received an incident report stating on 4/10/2023 Staff 1 (S1) conducted a medication count and discovered one capsule of Cephalexin 500mg over the amount of Resident 1’s (R1’s) prescribed medications. Additionally, there was a missing initial for 4/7/2023 at 12 pm. The incident report states the missing initial belongs to Staff 2 (S2). Incident #2 : On 4/25/2023, CCL received an incident report stating Staff 3 (S3) forgot to administer Resident 2’s (R2’s) 12 pm medication of Cephalexin 500mg (1 capsule) on 4/23/2023. The incident report states S2 discovered the capsule inside R2’s medication bubble pack. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit. Civil penalty issued.