Incident investigation·March 7, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator, Sarah Araya. LPA conducted risk assessment call with Administrator. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. During today's visit LPA is following up on an incident report received at CCL on 2/22/22 involving resident (R1) and staff (S1). On 2/22/22 Administrator received a call from S1 informing her that R1 had been given another resident's medication by error and R1 had fallen asleep during breakfast. Administrator called 911 immediately and R1 was transported to Kaiser Emergency Department. Administrator also notified responsible parties including North Bay Regional Center. Facility terminated S1 and staff is not longer working at the facility. Also, all staff received medication training on 2/22/22 and implemented a new process to designate a medication desk underneath medication cabinet were residents will come one at a time to receive their medications to avoid future medication errors. During this visit LPA reviewed R1's discharge paperwork and there are no medication changes for R1. ***Immediate civil penalty in the amount of $500 has been issued due to the medication error. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.