Facility Evaluation Report

At approximately 9:00am, Licensing Program Analyst (LPA) Loera and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Willie Hogan. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 10/10/2024 stating on 09/29/2024, Administrator Willie Hogan received a phone called from Staff 1 (S1) indicating the AM medication for Client 1 (C1) were missing. Administrator immediately went to facility and checked the bubble pack to confirm missing medication. Administrator then pulled medication from 10/31/2024 to administer to C1. (Deficiency Cited, LIC809D, regulation 80075(b)).

Incident Report 2: CCL received an incident report on 10/21/2024 stating on 10/16/2024 during the 6AM - 2PM shift Client 2 (C2) missed their medication. Incident report states that on 10/17/2024 when Staff 2 (S2) was passing medication S2 saw medication from 10/16 still in the bubble pack indicating they were not given. Administrator contacted their consultant to do retraining on medication administration. Training was conducted on 10/23/2024. (Deficiency Cited, LIC809D, regulation 80075(b)).

LPAs followed up on a Plan of Correction (POC) that was cited on 10/23/2024. CCL received proof of training paperwork. Review of training showed that documentation was incomplete - not all direct care staff attended the training for 10/29/2024. Facility submitted training for September 2024 which was before the citation was issued. LPAs are requesting for additional training to be submitted.

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 (Deficiency Page), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Administrator.