Facility Evaluation Report

On 08/4/2025 at 1:30PM Licensing Program Analyst (LPA) A Gomez conducted an unannounced Case Management visit regarding a self-reported incident. LPA met with Administrator Paolo Paredes, and explained the purpose of the visit.

A self-reported incident report was received on 7/21/2025 from facility that indicated Client 1 (C1) was administered C2s feeding bottle by mistake by Staff 1 (S1). The error was caught approximately 2 hrs later by S2. C1 was monitored and did not experience any adverse effects.

During the visit, LPA interviewed Administrator. Administrator states that the mistake was made by a newer staff member and that all staff have received an in service training as a result of the error. LPA observed that S1 had prior completed required training and had a signed off competency skill check dated 6/10/2025. The facility has also implemented a new procedure to verify that clients are receiving the proper feeding solutions. LPA issued a Technical Violation 80092.1(n)

Exit interview was conducted and a copy of this report was provided.