Facility Evaluation Report

On 08/03/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/13/23 and 07/14/23. LPA met with Administrator Marta Blanco and explained the reason for the visit.

Alta California Regional Center Special Incident Report submitted by facility on 07/17/23 to CCL stated that Staff (S1) did not give 1 scheduled medication to R1 on the morning of 07/13/23 and 07/14/23.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive, Amlodipine 5 mg( 1 tablet ) on the morning of 07/13/23 and 07/14/23 but staff did not give this medication to R1 as ordered by R1s physician .Facility noticed the medication error on 07/16/23 and found out that this medication was left in medication container for R1. On 07/16/23, Facility staff told administrator that they found 2 loose pills of Amlodipine 5mg in R1s medication container, and these 2 pills were missed and not administered per physician’s order to R1 for 07/13/23 and 07/14/23. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 07/17/23. Per facility’s reports, there were no changes to R1s health due to this med error and R1 was at their baseline. Based on this information, it was determined that facility did not administer this medication to R1 which poses a immediate health and safety risk to residents in care.

Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months.

The report was reviewed, appeal rights and a copy of this report was left at the facility.