Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management-Incident visit regarding a medication error on 6/5/2025 and met with Administrator Jennifer Ryder. LPA stated the purpose of the visit.

On 6/5/2025 the Department received an Incident Report (IR) for Client C1. The IR states on 6/5/2025 Staff S1 was notified by Staff S3 that Client C1 had a remaining medication that was not administered on 6/4/2025 by S2. C1 is prescribed Medication M1, with a dosage of 75mg (taken as two separate pills). S1 and ADM reviewed C1's Electronic Medication Administration Record (EMar) and saw that C1s two pills were logged in the EMar for on 6/4/2025. C1 did not receive the correct dosage of M1 on 6/4/2025.

LPA interviewed ADM, who stated Staff S2 did not realize only one pill of M1 came out of the bubble pack when administering to C1 on 6/4/2025. ADM stated both pills of M1 were incorrectly documented in EMar, and C1 only received one pill, an incorrect dosage, on 6/4/2025.

A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with ADM Jennifer Ryder and a copy of this report was provided. Appeal rights were also provided.