Facility Evaluation Report

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Jaime Gacilan and stated the purpose of today’s visit.

The purpose of this case management visit is to follow up on a medication error occurred on 8/13/2024. The Department received a Special Incident Report on 8/13/2024 regarding medication error for a client. Per incident report, Alta Regional Center, Service Coordinator Gurion conducted a Title 17 and noticed that client R1’s morning medication Protonix DR 40mg was not administered due to the pharmacy’s bubble pack was not correctly pack and dated therefore resulting in a missed medication dose.

During today’s visit, LPA Truong toured the facility and interviewed staff. It was learned that R1 has been taking Protonix (Pantoprazole) 40mg , 1 tab every other day. The pharmacy put R1’s Protonix in bubble pack, but it was out of sequence. There was no Protonix in bubble pack for 8/13/24. It was learned that staff signed off R1’s MAR on 8/13/24, but the medication was not given. R1 missed 1 day of medication and resume medication the next day.

Per California Code of Regulations (CCR) – a deficiency is being cited on the attached LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held and copy of report given.