Facility Evaluation Report

On this day, Licensing Program Analyst (LPA), Dwayne Mason Jr made an unannounced inspection to the facility for the purpose of following up on a Special Incident Report submitted by the facility to the Orange County Regional Office on November 15, 2023, regarding an incident involving a medication error. LPA was greeted and granted entry by facility Residential Supervisor (RS) Alexis Le after introducing self and stating the reason for the inspection.

Two staff members were interviewed on this day and LPA conducted a file review on Client 1 (C1). It was determined that Client 1 (C1) was given a higher dose of medication than prescribed. Based on staff interviews, LPA determined that on the day of the medication error, client vitals were taken, no changes were noted. Facility notified psychiatrist and followed psychiatrist’s recommendation. The staff who made the error received a final written warning and cannot go into the medication room until completing re-training on medication management. Client 1 (C1) was not interviewed because they no longer reside in the facility.

LPA was accompanied by Residential Supervisor (RS) and conducted a tour of the facility’s physical plant and made a Health & Safety inspection reviewing the facility’s routes of ingress and egress. No health and/or safety concerns were evidenced during the inspection.

Based on interviews conducted with staff, LPA determined that Client 1 (C1) was given a higher dose than prescribed on 11/15/2023. There were no adverse effects. RS stated that all staff would be re-trained. See deficiency page for deficiencies cited. Exit interview conducted and report was reviewed with Residential Supervisor, Alexis Le.