Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted a case management meeting with Mental Health Counselor, Debora Smith. Staff contacted Assistant Program Director Suhay Rivas for approval to sign for documents today . The case management is due to incident reports regarding medication errors submitted to Community Care Licensing (CCL) on 4/28/2025, 5/14/2025 and two on 6/19/2025.

CCL received a self reported incident report reporting on 4/28/2025, that on 4/22/25 at approximately 7 pm C1 was sent out due to panic attack. After evaluation C1 was admitted to ER due to elevated blood sugar levels. Further evaluation revealed doctors’ orders of daily blood sugar monitoring logs 5/2024 had not been implemented or documented. During today’s inspection LPA was informed C1’s blood sugar monitoring logs are being logged 2X per day by staff after C1 conducts test.

LPA obtained additional information regarding an incident that occurred on 4/29/2025 involving C2 (report not submitted to CCL until 5/14/2025, 15 days later -see LIC809-D reporting requirements 80061(b) ). At approximately 8am staff (S1) inadvertently administered C1’s 8 pm medications during AM distribution and did not discover until pm rounds, all appropriate parties were contacted, no adverse side effects observed. Report also indicates, S1 completed refresher training on distribution of medications. Assistant Program Dir. will submit training to CCL.

LPA followed up on an incident submitted to CCL on 6/19/2025 for an incident that occurred on 6/15/2025 when at approximately 7am S2 inadvertently give C3 another client’s morning medications. Appropriate parties notified. 911 arrived shortly after, assessed C3, and offered to transport to ER for observation. C3, not conserved, refused transport, safety monitoring plan put in place.