Facility Evaluation Report

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced Case Management Visit. LPA met with Hanna Diaz, to discuss the purpose of the visit.

Today's visit is in conjunction with a 10 day complaint visit for complaint # 29-AS-20260204125729 and in response to the incident report which involved Client 1 (C1) receiving two doses of medication that were not prescribed to C1 or any other client in the facility. C1 was admitted to the facility on 1/29/26 during PM shift. Records show the medication was logged on C1’s Centrally Stored Medication and Destruction Record (CSMDR), and the Medication Administration Record (MAR). The MAR indicates, via initials, that Staff 2 (S2) and Staff 3 (S3) administered the doses on 1/30/26 and 1/31/26. It is unclear why the medication was recorded and administered when the name does not match any clients. LPA took images of the medication bottle and confirmed that C1’s name was not on the prescription label. LPA obtained copies of the CSMDR and the MAR.

LPA did a medication audit of 3 clients who were admitted within a day of the incident, and all other records appear correct.

The staff who initially passed medication started 1/12/26. Detailed medication training records were not recorded. First shift alone of new staff was 1/30/26.

Based on interviews, and records, the incident posed an immediate health and safety risk to the client in care. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (LIC 9099-D).

An exit interview was conducted, a copy of this report and Appeal Rights printed.