Facility Evaluation Report

Licensing Program Analyst (LPA) Emily Peraldi and Rowena De Guzman, Community Services Specialist (QA) from North Los Angeles County Regional Center arrived to this location today for the purpose of conducting a Case Management – Incident visit regarding self-reported incident. At 1:10 p.m., LPA and QA were greeted and screened by staff. At 1:23 p.m., the Administrator arrived at the facility.

This visit was regarding an incident report that was sent to Community Care Licensing (CCL) on 01/30/2023 and received on 01/31/2023. The incident report stated that on 01/29/2023, during the morning Staff #1 (S1) was assisting with the self-administration of Client #1's (C1's) medication and C1 got frustrated due to not being able to open the water bottle. C1 proceeded to spit out C1’s medication and S1 did not call the house manager or the Administrator to notify them of the incident. Afterwards S1 proceeded to give C1 the same medications. S1 called the house manager and the Administrator an hour after the incident. Once the Administrator and the house manager were notified of the incident, C1 was sent to the Emergency Room (ER) due them not knowing if C1 ingested any of the original morning medications or if any of the medications were given twice. The hospital took C1’s blood level and C1’s levels were normal and C1 was healthy and safe to be discharged back to the facility. Additionally, on 02/01/2023, C1 had a follow up appointment with C1’s Physicians. Additional blood work was ordered and C1’s Physicians noted no problems.

On 02/01/2023, LPA Peraldi conducted an interview with the Administrator. The Administrator stated that S1 was terminated on 01/30/2023. The Administrator stated that the medication error was unacceptable and that all staff have been trained recently regarding medication. The Administrator stated that on 01/30/2023, the Administrator conducted an all staff meeting regarding the medication error.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued for the amount of $250. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email and print.