Facility Evaluation Report

07/22/2024 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with house manager Blanca Chavez. LPA contacted licensee Nora Serrano and obtained permission to meet with Ms. Chavez in Ms. Serrano's absence. Today’s visit is regarding an incident that occurred on 04/15/2024 and was reported to licensing the same day.

It was reported that on 04/15/2024 Far Northern Regional Center (FNRC) nurse Camarena performed an unannounced visit. While checking C1's medication log, it was discovered that on April 3 through 5, 2024 C1 had missed three dosages of Clozapine. The missed dosages were due to the medication not being delivered by the pharmacy. Staff contacted the pharmacy and the medication was delivered on April 5, 2024. Staff had signed the medication log as if they administered the dosage on April 5, but after looking at the medication bubble pack and counting the medication it was discovered that the dose for that day was not administered.

During the course of the investigation, it was learned the medication was ordered from the pharmacy a week before it ran out, and they said they would deliver. After two days the house manager called and checked and they kept saying they would deliver the medication. The house manager told staff to let them know a week in advance before a medication runs out. The house manager instructed staff to dispense the medication to C1 as soon as it was delivered by the pharmacy.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nora Chavez.