Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Administrator, Tsion Haile.

On 08/09/2023, the Department received an incident report regarding a missed medication for resident (R1) on 08/08/2023. The missed medication was found the morning on 08/09/2023 by staff. The missed medication is a routine medication that is used to prevent a medical condition. ADM states R1 is doing well. Family was informed and ADM stated the family communicated with R1's physician regarding the medication error.

Based on interview, it was stated that the staff (S1) who had administered the medication was not fully trained nor signed off to be administering medications on their own. The Administrator (ADM) states, S1 had administered medications that morning to help staff (S2) who was assisting residents with hygiene needs. ADM states the facility has a policy to have two people assist with medications for the second person to act as witness.

After the incident on 08/09/2023, the facility had S1 complete training on medication administration the same day, 08/09/2023. Based on record review, the facility last provided training on medication administration on 06/02/2023, to include S2.

During visit, LPA observed the facility completed medication administration training with all staff on 08/15/2023.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Tsion Haile and a copy of the report and appeal rights were provided.