Facility Evaluation Report

At approximately 9:30 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Administrator, Sheri Lott. The facility submitted one (1) Incident Report (IR) for Client 1 (C1) for a medication error.

The IR stated that on Thursday, 2/26/2026 there were five (5) staff members working who were new to working together as a team. There was some confusion as to who was administering the medications to client C1. As a result of the confusion, client C1 was not given their afternoon medications. At approximately 4:00 PM facility staff realized that client C1 was not given their afternoon medications. Facility staff immediately called the prescribing pharmacy. The pharmacy told the staff to Administer the clients' medications normally during the evening medication pass. Client C1 was monitored by facility staff and did not have any adverse reactions as a result of missing their afternoon medications. As a result of this error the facility is now assigning specific tasks for all staff members for each shift.

The facility will be cited for this deficiency.

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

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Lott. Signature on form confirms receipt of documents