Facility Evaluation Report

On 1/31/2025 at 1:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 1/10/2025. LPA met with Nicolas, Dedicatoria, Lead and explained the purpose of the visit.

The incident reported occurred on 1/09/2025. The report stated S1 was conducting a count of the medication and observed there were two (2) missing pills that belonged to C1. S1 reviewed verification checklist and observed three (3) pills were dispensed. S2 confirmed three (3) pills were given instead of one (1).

While conducting the case management visit LPA was informed another incident regarding mismanaging of medication occurred this morning. LPA interviewed three (3) staff. Two (2) of the three (3) was involved in the incident. S2 stated the 7 rights was completed and the medication was given to S3 to verify. S3 verified but gave medication to C2. Medication belonged to C1. S3 stated she verified the medication and assumed it was for C2 because C2 was her assignment. C2's doctor was contacted and was told to bring C1 to Sutter Delta Medical Center.

LPA obtained the after-summary visit for C2.

*An immediate $250.00 civil penalty will be assessed on today's date for repeat deficiency*