Facility Evaluation Report

On 10/3/23 at 2:16 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management inspection - incident inspection. LPA explained reason for inspection and met with Administrator (ADM) Darlene Hathcock.

On 9/15/23, CCL received a Special Incident Report (SIR) from the facility reporting S1 did not administer R1's Med1 on 9/14/23 for the 2AM dose.

LPA conducted interview and reviewed records. ADM states the missed dose was discovered when ADM arrived in the morning and saw that Med1 was not signed for. ADM states S1 reported R1 was asleep at the time and S1 forgot. Immediately upon discovery, ADM notified supervisor, behaviorist, and contacted R1's PCP for an appointment to address the missed dose. ADM was able to conduct a tele health appointment with R1's nurse practitioner at the lunch hour. R1 did not experience any adverse reactions. S1 has been removed from self-administration medication assistance for all residents in the facility until S1 has been retrained.

A deficiency is being cited based on LPA interview conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator Darlene Hathcock, whose signature on this form confirms receipt of these documents.