Facility Evaluation Report
On 01/28/2026 at 3:40 p.m., Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit in response to an incident reported to the Community Care Licensing Division (CCLD) on 11/11/2025. Upon arrival, LPA met with Direct Support Professional (DSP) Sally Bunde and advised her of the purpose of the visit. Ms. Bunde notified Administrator Denise Mansfield by telephone. Lead Staff Edith Nantumbwe arrived shortly thereafter.
The Special Incident Report (SIR), dated 11/11/2025, documented a medication administration error that occurred on 11/10/2025, in which DSP1 administered a double dose of Acyclovir to Client C1. Staff #4 (S) S4 stated that DSP1 was immediately removed from medication administration duties and required to complete remedial training. S4 further reported that DSP1 completed medication management training through Relias and an additional four (4) hours of in-person medication training facilitated by S5.
During the visit, LPA reviewed and obtained documentation verifying DSP1’s completion of the required four (4) hours of in-person Medication Management training and the Relias one (1) hour “Providing Medication Assistance and Documentation – California” course.
No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to facility representatives.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction