Facility Evaluation Report

On 12/16/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management based on self reporting incident received on 10/14/24. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry.

LPA observed 1 out of 2 residents in care at the time of the visit. During a medication audit, Administrator identified a medication error by Staff S1 on a routine medicine (Ferrous Sulfate) for Resident R1. S1 gave R1 the medication daily for 3 days instead of 3 times a week. Administrator contacted the Physician Assistant to report the error. Facility put R1 on increased monitoring per PA. No adverse reactions were observed.

Based on observation and record review, the licensee failed to ensure medication was given as prescribed by the doctor in 1 out of 2 residents, which poses a potential risk to residents in care. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D. The plan of correction has already been cleared prior to LPA arrival.

An exit interview was conducted. A copy of this report and appeal rights were provided at the time of visit.