Facility Evaluation Report

On 03/12/25 ,Licensing Program Analyst (LPA) Talwinder Bains arrived at the above to conduct a Case Management visit regarding an incident that occurred on 02/27/25. LPA met with Program Administrator, Latisha Woodson and explained the reason for the visit.

Alta California Regional Center Special Incident Report (SIR) submitted by facility on 02/27/25 to CCL stated that on 2/27/25, around 12:00 pm, staff 1 (S1) administered resident, R1s noon medication. S1 mixed two capsules of Depakote 250 mg with applesauce and handed the bowl to staff 2 (S2). Unaware that the medication had already been mixed by S1, S2 mixed additional two capsules of Depakote 250 mg with applesauce and gave to R1.

Based on incident report, staff interviews, medication record review, it has been concluded that staff gave double dose of Depakote 250mg which was not prescribed by R1s physician. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 02/27/25.

Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D.

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