Facility Evaluation Report

On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator .

The department received 5 incident reports for client missed medication.

LPA reviewed the reports with the Administrator as well as reviewing programs medication procedures.

The medication errors involved R1, on 1/25/25 and 1/27/25, R2, on 1/25/25 and 1/26/25, and R3 on 2/1/25. The 25th -27th errors were discovered in medication audit. Those staff responsible will be determined and retraining provided. The staff responsible for the 2/1/25 error , S1, is currently under supervisory review.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided