Incident investigation·January 9, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management - Incident visit. LPA met with Robert Alvarado, Administrator. On 12/23/24 facility submitted to CCL an Incident Report indicating that on 12/21/24 facility received reporting that resident (R1) was missing $500-$600 dollars in cash from their wallet. R1 reported to facility that they had last seen their money in their wallet when leaving the hospital on 12/19/24. R1 also reported the missing money to their family at an unknown date and time. Per Incident Report submitted, upon receiving the report of missing money, the acting Admin was notified immediately by facility receptionist. R1's room was subsequently searched by Resident Care Coordinator (RCC); however, no money was recovered/found. Facility then notified Santa Rosa Police Department (SRPD) of the missing money and the issued case number was provided to CCL. The local ombudsman was also notified of the incident on 12/21/24. Additionally, facility RCC self reported the incident on a SOC341 to CCL on 12/23/24. No deficiencies cited for this incident. On 1/6/25 CCL received an Incident Report regarding a medication error for resident (R2). R2 was given another resident's medications: Acyclovir, Metformin, and Pravastatin. Facility notified Emergency Medical Services (EMS) and R2 was taken to the hospital for evaluation. All required partied were notified by facility. Continued on 809C... Continued from 809... Per Incident Report, R2 was diagnosed with non-toxic accidental ingestion and returned to the facility the same day. Resident placed on 72 hour alert charting ( deficiency cited, see 809D ). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .