Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of several incident reports (SIR) for client (C1). LPA met with House Lead, Crystal Paulus and DSP's, Jeanne Gold and Stacey Takara. LPA observed staff Jeanne to be playing a game at the table with client (C2). The new Administrator, Kizzy Thorn, had just left the facility prior to LPA's arrival. LPA discussed SIR's for (C1) from 10/23/23 and 10/29/23 where (C1) refused bedtime medications.

The House Lead assisted LPA in reviewing Medication Administration Record (MAR) for September 2023 showing missed bedtime medications (4 dosages) for (C1) from 9/8/23- 9/27/23. LPA discussed the reason for the missed medications with the House Lead, DSP and facility nurse, Alex. All interviews revealed that (2) psychiatric medications were not filled timely and (C1) missed the (4) dosages. As a result, (C1) had behavioral concerns during this time period. The nurse stated to LPA that the new psychiatric physician wouldn't refill any prescriptions until (C1) was seen in person, which (C1) was refusing to do on multiple times. DSP stated that staff finally was able to have (C1) go to his primary care physician who asked to confirm which medications needed a refill. The earliest (C1) could be seen was on 10/20/23 with the psychiatric doctor.

DSP and House Lead stated there is not a refill number listed on the medication bubble packs and they do not monitor the refill status. LPA observed the bubble pack for (C1) and did not see a reference to any refills. LPA observed on pharm acy paperwork, dated 6/9/23, that (2) refills were available for the (2) psychiatric medications that ran out on 9/8/23. The Administrator at the time sent a SIR to the Department on 9/9/23 to report that (8) medications prescribed from (C1's) primary care physician were missed on 9/9/23 due to wildfire at that time; however, a SIR was not sent for the (2) medications ((4) dosages) missed from 9/8/23- 9/27/23.

Per California Code of Regulation Title 22, Division 6, Chapter 8, the following (2) deficiencies are issued on the 809D page.

Exit interview. Copy of report and appeal rights emailed due to technical difficulties.