Facility Evaluation Report

At approximately 8:10AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted by the facility on 07/29/2024. LPA met with Administrator Talisha Rose and reviewed records. On 07/18/2024, Facility staff were conducting a pill count and observed Client, C1, had only received 1 pill of a 2 pill order for the previous 4 days. The medication usually is packaged together, but the recent order came packaged separately. On 07/29/2024, Administrator conducted retraining with responsible staff and posted a reminder to all other staff to ensure they slow down and pay attention during medication time. An immediate civil penalty is being issued in the amount of $250 for this repeat violation in a 12 month period.

During this visit, LPA received another incident report regarding Client, C2, not receiving 2 doses of their medication. The medication was ordered on 08/10/2024, but the pharmacy made an error and sent the refill request to the wrong physician. The missing medication was noticed 08/19/2024, as it was not available to administrator. Administrator contacted pharmacy and physician and was informed the medication would be filled immediately. Facility has updated their medication ordering process to keep better track.

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 Talisha Rose and Appeal rights were given.