Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores and Mita Partoza arrived unannounced to conduct a case management – incident visit. LPAs met with Director of Operations David Sandhu and Administrator Lucero Rodriguez.

On 11/29/2023, the Department received an incident report regarding a missed half dose of medication for resident (R1) on 11/26/2023. Based on the report, R1 did not receive a single tablet of medication. Based on interview with the Director of Operations and Administrator, R1 had an increased dosage of medication from 25mcg to 50mcg. On 11/26/2023, R1 only received 25mcg instead of 50mcg. The staff did not catch the increase of dosage for R1. It was discovered the next day on 11/27/2023 that R1 only had received 25mcg of medication, half the required dose.

After the incident, the facility completed an in-service training with appropriate staff on 12/13/2023 on additional topics to include medication and medication verification. Facility also completed an "after the incident training" and medication dispensation training for the staff involved in the medication error.

During visit, LPA obtained the training sheets and training transcripts for S1 and S2.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Director of Operations, David Sandhu and Administrator Lucero Rodriguez and a copy of the report will be provided via email due to printer errors.