Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management visit today to follow-up on an incident reported to the department on 10/8/25. LPA, met with Montrey Taylor-Vaughn, Program Coordinator and Mikayla Baum, Case Manager and the reason for the visit was explained.

Today’s visit stems from a Special Incident Report (SIR) which occurred on 10/3/25. According to SIR, it was reported to the adult day program’s (ADP) management on 10/7/25 that Consumer 2 (C2) took home another consumer’s (C1) medication on 10/3/25. SIR report indicates that ADP staff called C2's home to notify them of the medication error. Staff from the home retrieved the medication and returned it to the day program. SIR also indicated that the day program’s staff gave C1 back-up medication so that C1 would not miss a dose.

Interview with Staff 1 (S1) indicated that Staff 2 (S2), who gave C2 C1's medication to take home, received temporary suspension as part of the corrective plan. S2 returned to work and received individual training from S1. Furthermore, S1 provided training for all staff who assist with medication administration and documentation, as a refresher.

During today’s visit, LPA obtained copies of staff and consumer rosters, reviewed and obtained copies of training/qualification documents and Job Description for S2 and sign-in sheets for (2) trainings and topics for Medication Administration Remediation.

During today’s visit, a deficiency is noted, and citation is being issued today. Exit interview was conducted with Montrey Taylor-Vaugh, Program Coordinator and a copy of the report and Appeal Rights were provided.