Incident investigation·November 5, 2024

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met house manager Janet Salvador (HM) . This is an amended report due to new information from 11/5/24. On 10/30/24, the Department received an incident report reporting that a resident (R1) accidentally took other resident's medication. LPA interviewed Licensee (LCN), ADM, 1 staff, and 2 residents. During interview, LCN stated on 10/29/2024, he/she received a report from staff S1 that resident R1 had a medication error incident. LCN stated this was the first incident of medication error occurred in the facility. Staff S2 stated he/she found resident R1 took resident R2's medications while he/she was going to administer medication to resident R2. LPA obtained a copy of the incident report and LCN stated that they had notified R1 doctor regarding the incident. A copy of R1's doctor's instruction was obtained during visit. LPA reviewed/checked R1's 6 medications with R1's November 2024 centrally stored medication form/log, and they were all matched by counting the amount or number of medication in the bottle and cross referencing log. During visit on 11/5/24, the Department inadvertently did not issue a citation on the medication error. Therefore, a citation under Title 22, section 87465(a)(4) is being cited for today. Please see LIC809 and LIC809-D for deficiency. Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.