Facility Evaluation Report

On 02/22/2023, Licensing Program Analysts (LPAs) Bains and Muscan arrived at the above to conduct a Case Management visit regarding an incident that occurred on 02/10/23. LPAs met with Administrator Shoa Johnson and explained reason for visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical masks.

Alta California Regional Center Special Incident Report submitted by facility on 02/13/23 to CCL stated that at 9pm on 02/11/23, the Administrator was notified by the lead on duty that there was a missing signature for R1's 8pm medications for 02/10/23, The administrator followed up with the lead from that day and they stated that they had recalled the medications being passed. On 02/11/23, the Administrator went to the facility to make sure the medications were given. and ensure the information given was accurate. The Administrator reviewed the MAR and the medication bubble packs and concluded that the medications- Cloridine 0.2mg-1tab, Gabapentin 600mg-1tab , Melatonin 3mg-2 tabs , Olanzapine 10mg-1tab were NOT given on 02/10/23 to R1 as prescribed by R1s physician.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive all these medications for 02/10/23 for evening/night but facility missed that medication for R1. It was determined the S1 had followed protocols while preparing the medications, however, failed to prepare the Cloridine 0.2mg-1tab, Gabapentin 600mg-1tab , Melatonin 3mg-2 tabs , Olanzapine 10mg-1tab as final medication on the MAR. Facility notified R1s physician, CCL, ALTA and other agencies regarding this Medication Error on 02/13/23.

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.