Incident investigation·November 7, 2024

On 11/07/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Maria Castillo-Padilla and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 11/05/2024. Current census was 108. A brief interview with FDR Padilla was conducted. On 11/05/2024, the department received a Special Incident Report (SIR) from this facility stating that on 11/04/2024, a medication technician provided the wrong medication for R1. R1 was provided Lorazepam 1mg intended for another resident instead of their routine medication of Alprazaam 0.5mg. The Medication Technician notified facility management, who called poison control and provided directive to put the resident on a 72 hour observation period. The facility took the resident's vitals and additional check ins were conduct as requested by poison control. The facility will plan to conduct additional training on the 7 rights of medication as well as supplemental training for S1. Based on the information gathered during the course of this visit, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.