Facility Evaluation Report

Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a report submitted by facility on 09/04/2025. LPA met with Director Alan Coulter and reviewed records. Based on records reviewed, staff gave the wrong dose of a medication to a client. The staff had recently returned from vacation and did not check that the medication was for the correct client or the correct dose. A second error occurred on 09/08/2025, by a different staff. This incident involved a staff who misunderstood the instructions on the Medication Administration Record, MAR, and gave C1 the insulin injection pen at the incorrect time, resulting in C1 getting an additional dose of insulin.

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 Alan Coulter and Appeal rights were given.