Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Kelly Sturgeon.

LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 01/06/2023 of a medication error. The error was identified on 01/02/2023 that included 8 previous errors in the past month due to pm shift staff accidentally over medicating resident on antidepressant medication. (See LIC809-D) Responsible party and prescribing physician were notified of the medication error.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided