Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on an Incident Report self-reported on 10/23/2024 regarding medication error which occurred on 10/22/2024. LPA Rai met with Program Manager (PM) Felicia Lehner and stated the purpose of today's visit.

On 10/22/2024 at 11am, facility staff observed R1 was not administered medication #1 during the evening for 10/21/2024 as they observed medication #1 tablet was not popped out of the bubble pack.

During today's visit, LPA Rai reviewed facility training from 11/1/2024 through 11/6/2024, facility staff were trained on Medication Management & using the Centrally Stored Medication & Destruction Record.

Administrator in training stated all staff in the facility will be receiving re-training on medication and best practices for medication administration and specific steps to prevent missed doses in the future.

LPA Rai requests the written plan of action for medication error and the specific steps to prevent missed doses in the future.

An Advisory Note was issued. See LIC9102 for more information.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Program Manager (PM) Felicia Lehner and a copy of this report was provided.