Facility Evaluation Report

At approximately 2:15 PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management Inspection on an Incident Report dated 01/10/2024. LPA met with Team Leader, Jacquie Burns and discussed the purpose of the visit.

Incident Report dated 01/10/2024: Client 1 (C1) did not receive a scheduled dose of Metformin. Staff 1 (S1) could not recall why it was not administered when Team Leader asked about the medication error, but S1 claimed that its possible that the medication was in a new medication roll and it was not visible to them at the time, causing them to forget to administer the medication.

Per conversation with Team Leader, staff members handle medication passes differently, with some staff allowing clients to sleep in and get their medications when they wake up. Team Leader has had conversations with staff in the past about making sure that if a client doesn't show up for medication pass, that it is their responsibility to get the client and ensure that they are taking their meds within the required time frame. In this instance, it is unknown why the medication error occurred. In addition, the client did not suffer any adverse affects.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Team Leader. Signature on form confirms receipt of documents.