Incident investigation·March 12, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility administrator, Patrick Seawright. Administrator could not be present for entire LPA visit. LPA conducted exit interview with and gave appeal rights and copy of report to caregiver. On 9/17/24 CCL received an incident report from the facility regarding a medication error. Reports states that on 9/17/24, due to staff error, resident (R1) did not receive their dose of Amuity Ellipta 200mcg. R1 did not receive the medication due it being empty, a refill was not ordered in time. Reports indicates that R1 was monitored throughout the day for any adverse effects. No signs or symptoms of adverse effects observed. Per Admin, facility put in place ordering procedures to mitigate errors in refilling of medications. As of today, 3/12/25 CCL has not received any further incident reports for medication errors from the facility. 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 caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. On 1/13/25 CCL received a SOC341 from the facility self-reporting a case of abuse toward a resident by a staff member. Facility Admin, Patrick Seawright submitted the SOC341 report. Report indicates that on 1/6/25 staff (S1) observed staff (S2) push resident’s (R2) wheelchair on to R2’s knees in an attempt to get them to get into their wheelchair. On 1/6/25 S1 reported this incident to a new hire orientation trainer. The new hire orientation trainer sent an email to People’s Care QA auditor. On 1/8/25 S1 then reported the incident to facility Admin. Facility Admin then immediately went over to R2 to check the status of their legs Continued on 809C... Continued from 809... and observed no marks or bruising. On 1/12/25 facility Admin contacted S2 and placed them on Administrative leave. As of today, 3/12/25 S2 is back on active duty at the facility. Starting on 1/8/25 People’s Care Quality Assurance auditor (QA) began an investigation into the incident. Investigation lasted approximately one week and took another 2 weeks to report their findings. Admin advised LPA they did not receive any written statements from the staff. LPA asked Admin for the findings of the investigation. Admin advised they can produce the findings for CCL by 3/31/25 as they must ask the investigator for a copy of the findings. Per Admin, due to inconsistent details of the incident being reported to the QA investigator over the course of the investigation, S2 has returned work. Facility Admin reports R2 has not had any adverse behaviors observed resulting from the incident. No deficiencies cited for this SOC341 incident. Exit interview conducted with caregiver and a copy of this report was given .