Incident investigation·April 21, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on a self-incident report dated 4/7/25 received by Community Care Licensing (CCL) regarding a medication error and met with Daniela Oseguera, Business Office Manager (BOM). Per incident report: "On 4/4/25 at about 10am the staff (S1) telephoned pharmacy to obtain clarification around an order written by resident's (R1) neurologist to input it into the facility electronic medication records (MARs). It was reviewed that it was populating on the MARs was on 3/20/25 Namenda 5mg once per day per one week and on 3/21/25 Namenda 10mg 2x/day was also started, which then overlapped with the other Namenda dosage and continued to overlap until the morning on 3/30/25. Namenda 5mg 2x/day for one week began on 3/28/25 when the 1x/day dosing was completed. No further Namenda was given as it had run out and a supply reorder was pending with the pharmacy. Responsible parties were notified. R1 was placed on alert charting and monitored for any side effects of the medication overdosing, but R1 has not complained about any discomfort and no further incidents have occurred. According to incident report, R1's care plan has been updated and medication technicians will be re-trained on checking all resident's medications orders prior to begin assisting them with their medications". During today's visit, LPA requested R1's updated care plan, physician's report, medication administration records and staff training records. Per BOM, the facility agreed to submit requested documents to by not later than 4/22/25. 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. **Civil penalty assessed for repeat violation within 12 months** Exit interview conducted with BOM and a copy of this report was given.