Complaint Investigation Report

374601153-4-19-2023-08-AS-SJAB-CSBRYB-20230530132601

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 7575 METROPOLITAN DR. #109

This is an official report of an unannounced visit/investigation of a complaint received in our office on

04/16/2021 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20210416133441

Facility staff mismanaged clients' medication

Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Kathy Nelson, Administrator to discuss the purpose of the visit. LPA conducted interviews, made observations, and obtained and reviewed pertinent records. It was alleged that facility staff mismanaged clients' medication. Interviews revealed that on April.12, 2021, Client 1 (C1) was given the wrong injection by the staff. Interviews revealed the staff put down the intended injection for C1 when C1 swung at them. Staff then picked up the incorrect injection (Enbrel) and gave it to C1. Interviews revealed the error was caught immediately, staff called the the doctor and they were advsied to still give C1 the correct injection. Based on the evidence obtained from interviews, and records review, the complaint allegation is substantiated.

An exit interview was conducted with Kathy Nelson and a copy of this report along with\ Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.