Facility Evaluation Report
On 04/17/2025 at 8:35 AM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced case management visit regarding an incident report that was reported to CCLD on 03/28/2025. LPA met with Administrator, Desiree Fredeluces, and explained the purpose of the visit.
On 03/28/2025, LPA P.Manalo received an Incident Report regarding missed seizure medication for client 1 (C1). The Incident Report indicated that C1 missed a dose of their medication on 03/27/2025 at 8:00 PM. Based on record review, LPA observed that the Medication Administration Record (MAR), was signed by staff even though the medication was not provided to C1. Two staff on duty confirmed with LPA that C1's night medication was not given, but the MAR was signed off. Administrator confirmed that on 03/28/2025 the medication was still in the bubble pack.
During the visit, LPA obtained and reviewed the Coaching Record, Facility's Fax to the doctor for missing medication, March MAR, Nursing Notes, Staff Schedule, Medication Training Log for all staff, Seizure Logs, March Medication Bubble Pack.
Moving forward, the Administrator will implement a two person MAR Sign-off and Narcotic Count Sheet moving forward.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction