Facility Evaluation Report

At approximately 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to two incident reports submitted by the facility. Incident #1: On 05/04/2026, staff were conducting a medication count and discovered an error. The previous days medication staff administered a medication that had been discontinued instead of the current prescription. The discontinued medication was still in the drawer. Physician was notified and client was monitored for adverse reaction. Medication procedures were updated on where discontinued medication is stored and retraining was conducted with responsible staff.

Incident #2: On 05/15/2026 at approximately 9:00AM, staff observed a client (C1) hunched over in a low visibility area of the back yard of the facility. Staff responded and checked vitals while emergency services (EMS) were contacted. EMS arrived and administered NARCAN and transported client to the Emergency room. LPA was informed C1 was in the process of being discharged from the facility prior to this incident. C1 was released from the hospital at approximately 12:00PM, and returned to the facility. LPA spoke with facility about the storage and use of NARCAN at the facility.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Alana Roberg and Appeal rights were given.