Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management 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 7/30/2024 of a medication error. The error occurred at morning medication pass on 7/29/2024 while employee was dispensing medication. Caregiver inadvertently gave resident (R1) another resident’s medications during medication passing Regulation 87465(a)(4). (See LIC809-D). Hospice Dr. & pharmacy contacted regarding medications. R1 monitored with only signs of dizziness. Prescribing physician and responsible party were notified of medication error. Review of in-person (6 hr) training for medication administration was provided to caregiver on 7/30/2024.

LPA was provided medication training documents.

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