Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen was at facility conducting complaint investigation and conduct a Case Management - Incident Visit and met with Administrator, Sheri Lott. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL).

CCL received an incident report on 8/13/2025. Report stated that on 8/11/2025, at approximately 8am staff (S1) accidentally administered medication to Client (C1) that was for another client. S1 contacted Administrator to report the error. The pharmacy was contacted regarding the error.

Per conversation with Administrator, staff monitored C1 for any changes. Was told by the pharmacist not to administer any medication to C1 for a 12 hour cycle. Medication for C1 were resumed at 8pm same day. S1 is in the process of being retrained for medication administration procedures. Facility made all appropriate notifications per regulation. (see LIC809D). Facility had medication error with same client, same situation 3/4/2025.

Additionally, when LPA arrived at facility (8/21/2025) at approximately 8:50am there was only 1 staff (S2) who was still there from the overnight shift (NOC) with 4 clients as 1 was at skilled nursing facility. LPA was informed other NOC shift staff left at approximately 8am. The morning shift staff did not arrive until approximately 9:15am. (see LIC809D)

The following deficiencies were observed (see LIC 9099D) 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. Copy of report, LIC809D, LIC 811 (Confidential Names), and Appeal Rights discussed and provided to Staff.