Incident investigation·March 4, 2025

Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced case management inspection and met with Interim Administrator Robert Coe, The purpose of this case management inspection is to follow up on two self reported incident reports submitted to Community Care LIcensing (CCL) 2/5/2025 & 3/3/2025. CCL received a self reported incident report reporting on 1/28/2025 resident (R1) was inadvertently administered another residents medication. Primary care physician (PCP) immediately notified along with family and monitored for any negative effects for 24 hours, no adverse side effects noted. Facility conducted in-service with staff and Consonsus pharmacy came out following day and shadowed pass. Facility has hired LVN to oversee medication room/care department. LPA followed up on a second medication error that occurred on 2/24/2025 when after medication review it was found R2 had been receiving incorrect dosage of medication since start on 2/21/2025. PCP on cite informed along with family. Indicated R2 showed no adverse side effects. Staff training in progress. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Interim Administrator. Appeal rights provided.