Facility Evaluation Report

On May 1, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management Incident inspection. LPA is following up on a self reported incident report that was received by the Orange County Regional Office on March 13, 2026, regarding a medication error for Client #1 (C1) that occurred on March 9, 2026. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Clinical Operations Manager Solara McCoy and Clinical Director Sara Smith were notified and later arrived to assist with the inspection.

On today's visit, LPA observed five clients. LPA, accompanied by a staff, conducted a tour of the physical plant. LPA observed the facility to be clear of any obstructions and hazards. No health or safety concerns were observed. LPA additionally reviewed and obtained pertinent documents for the incident which included the initial psychiatric evaluation and medication records for C1. Per the facility's medication records for C1 dated March 9, 2026, it states that C1 missed her prescribed routine medication, Phenzazopyridine Hydrochloride 200 MG tablet, due to a staff error from Staff #1 (S1). LPA conducted two staff interviews. Two out of the two staff interviewed confirmed that a medication error occurred on March 9, 2026 due to a staff mistake. LPA also observed that S1 has received retraining on medication administration as a result of the incident.

Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. The deficiency will be cleared at time of visit due to S1 already receiving retraining from the facility. An exit interview was conducted with Clinical Operations Manager Solara McCoy and Clinical Director Sara Smith. A copy of the report and appeal rights were provided.