Incident investigation·April 18, 2023

Licensing Program Analyst Bertozzi arrived unnanounced to conduct a Case Management inspection and met with Resident Care Director, Tiffany Leos. Administrator, Cynthia Gamino was unavailable. LPA is following up regarding a self-reported incident where resident, R1 missed their medication due to it not arriving from the pharmacy in a timely manner. LPA reviewed Chart notes and medication documents and spoke with staff. R1 receives a 30 day supply of medication on a regular schedule.. Facility ran out of medication on 3/15/2023 and contacted he pharmacy who told the facility that the medication would not be sent until 4/10/2023 because the facility had marked on their form that the medication was not needed for the March refill. Per interview, the Medication Technician did not realize that the form was incorrect and has since been re-trained to ensure that resident's medications are received timely. 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.