Facility Evaluation Report

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to review the circumstances surrounding an incident report submitted to Community Care Licensing. At the time of LPA's arrival, there were 7 clients & 3 staff including Elizabeth "Liz" McCann - Program Director of RSS and Casa Rene who LPA met with as Assistant Program Director (APD) Steven Hainbuch is covering a later shift.

The self-reported incident occurred on June 27, 2022 and involved a client receiving the wrong dosage of prescribed medication. Per doctor’s order C1 is to receive 500mg of medication in the am and 1000mg of medication in the pm. On 6/27/2022 S1 gave 1000mg in the am. Per the incident report, staff failed to review the dosage and client was over-medicated. The overdosage of medication was reported to Assistant Program Director, client was monitored and noted no adverse side effects reported. Consultation with county public health psych NP.

LPA reviewed the facility's "Medication Protocol" with Program Director. Additional safeguards and precautions have been put in place. Supervisor met with psych NP of county health to review incident. Staff is scheduled to attended refresher training on medication procedures through Relias and has been shadowed & shadowing during medication passes.

LPA is citing the facility for failure to assist a client with self-administration of prescription medications correctly.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. .