Incident investigation·February 13, 2024

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Rod Moshiri. The purpose of the visit was to address incident reports filed by the facility concerning medication errors, including an LIC624 Unusual Incident/Injury Report for an incident that occurred on 12/09/2022 and reported to the Department on 12/15/2022. The incident from 12/09/2022 involved a medication technician who gave another resident's morning medications to resident R1. LPA Marrufo requests that the facility submit a Plan of Action to the Department by 02/20/2024 explaining how the facility will train staff and prevent medication errors. An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Rod Moshiri and a copy of the report was provided.