Facility Evaluation Report

An Office Informal meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager (LPM), Victoria Bertozzi, Licensing Program Analyst (LPA), Caitlynn Felias, Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam Perez . The purpose of today’s meeting was to address recurrent medication errors at the facility and to deliver findings for Complaint 21-AS-20241217093631.

The following areas were discussed during the meeting today:

Findings for Complaint 21-AS-20241217093631 were delivered (LIC9099)

Recurrent Medication Errors that were cited on case management visits or complaint investigations. Citations issued on 11/02/2023, 2/8/2024, 3/1/2024, 3/8/2024, 7/24/2024, and 12/5/2024

Incident Report of a medication error on 04/07/2025.

Parties discussed Facility's plan moving forward regarding medication administration. Facility has decided to conduct competency checks along with shadowing to ensure quality assurance. Facility to submit a written plan and supporting documents by due date 05/01/2025. Failure to correct these issues may result in a Non-Compliance Conference and being placed on a Non-Compliance Plan.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.