Incident investigation·October 2, 2024

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit due to three self-reported incidents of medication being found on the floor in three residents' rooms. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison. LPA explained the reason for the visit to acting administrator Roman Sierra Tovar. At 1:38 LPA and QAS spoke with administrator. At 1:50 p.m. LPA and QAS reviewed and obtained pertinent documents. At 2:04 p.m. LPA and QAS conducted a brief tour of the facility. At 2:12 LPA and QAS interviewed medication technician staff 1 (S1). On 9/18/2024, a medication technician found a medication on the floor in the room of resident 1 (R1). On 9/20/2024, a medication technician found a medication on the floor in the room of resident 2 (R2). On 9/23/2024, a medication technician found a medication on the floor in the room of resident 3 (R3). S1 stated they always make sure all medication is taken by a resident before they leave the room. S1 is not on the same shift as other medication technicians so they were not sure how other medication technicians distribute medications. S1 found a medication on the floor, properly discarded the medication and reported it to management. R1, R2, and R3 all have physicians' reports which state they cannot have access to medication. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.