Facility Evaluation Report

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Ruth Martinez for the purpose of following on a self-reported incident report received on October 04, 2023 regarding a medication error involving Client #1 (C1) that took place on October 04, 2023. LPA arrived at facility was greeted and granted entry by staff. LPA met with Autumn Carter, Care Coordinator III and explained the nature of the visit.

The incident report states the following: On October 04, 2023, C1 was given the wrong dose of medication, C1 had no adverse reaction to incident, C1 was monitored and was given a set of vitals, and all required responsible parties were notified. C1 did not need additional medical treatment.

During today’s inspection, LPA was informed C1 was discharged on October 17, 2023 and LPA observed no health and safety issues. LPA interviewed staff #1 (S1) regarding the incident. LPA was informed facility immediately following the incident was retrained by facility Nurse and shadowed for S1's shift on medication distribution.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.