Incident investigation·May 10, 2024

On 05/10/24, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit regarding a medication error. LPA Campbell met with Administrator Sr. Basima Margaret Homa and explained the purpose of the visit. Per the incident report provided to licensing, Resident 1 (R1) received the incorrect dosage for 4 days. R1's doctor was immediately notified. The Administrator reported that the Med Tech (M1) involved in the medication error was involved in other ongoing issues regarding their performance. M1 then resigned when required to write a report recounting the incident. The administrator also stated that M1 had already given two weeks notice beforehand. Per the doctor's orders, a "plan of correction" was needed to avoid the mistake being repeated. The administrator now requires that 2 staff will need to check and verify accuracy before making changes to the doctor's order. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.