Facility Evaluation Report

On August 18, 2025, 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 July 17, 2025 regarding a medication error for Client #1 (C1). LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Program Manager (PM) Alexis Le was notified via telephone and later arrived to assist with the inspection.

On today's visit, LPA observed six clients in care and four staff present. LPA, accompanied by PM, 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 include medication administration records and staff training. LPA also conducted one staff interview.

Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with Program Manager Alexis Le. A copy of the report and Appeal Rights were provided.