Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Luis De Leon conducted a Case Management Visit-Incident on 01/02/2025, stemming from Special Incident Report received on 12/10/2024. LPA was greeted by House Manager- Nina Donini and explained the purpose of the visit. Administrator Jorge Romero arrived shortly after.

On 12/5/2024. S1 erroneously dispensed C1’s bedtime medication of Doxepin (25mg) & Diphenhydramine (50mg) during afternoon (3pm) medications pass. During bedtime medication pass (10pm), S2 dispensed an additional dose of Doxepin (25mg) & Diphenhydramine (50mg), that C1 already received earlier during afternoon (3pm) medication pass. S2 discovered their error and immediately notified Administrator Romero. Facility nurse, Community Care Licensing, C1’s primary physician and San Gabriel/Pomona Regional Center were notified on 12/6/2024. According to Administrator Romero, these medications were not PRN medications (as the need arises) but, scheduled medications that C1's primary physician ordered to be administered.

On 12/9/2024, S1 and S2 received 2 hours of in-service medications training. On 12/23/2024, S1 and S2 received a Performance Improvement Plan that documented their performance on 12/5/24 and action taken by the facility.

Based on records reviewed and interviews conducted, one (1) type A deficiency is being cited for violation of Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements- 80065 Personnel Requirements- (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

Exit interview was conducted and a copy of this report, 809-D and appeals rights was provided via email.