Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to deficiencies observed and cited by Alta California Regional Center (ACRC) on/around 4/27/2023. LPA met with Encarnacion Carmen, DSP, who contacted LuzviMinda "Mindy" Cailing, DSP, by phone. LPA spoke to Mindy, and explained purpose of inspection. Mindy stated she was not able to meet LPA at the facility now and agreed to contact Maye Dickey, Administrator. LPA met with Maye Dickey, Administrator, at approximately 1:45 pm and explained purpose of inspection. Administrator confirmed (4) residents were attending day program during the inspection. LPA observed (1) client return during the inspection.

LPA reviewed the Facility Action Report/Corrective Action Plan provided to the Department by ACRC on 5/25/2023, describing the specific deficiencies found. Also provided was a letter explaining the facility had been placed on Sanctions as of 5/25/2023 due to (2) substantial deficiencies at the facility within a (12) month period. The deficiencies were observed on 4/27/2023, as follows:

Medication error was discovered for Client (C1) . Specifically, the medication Xcopri 12.5mg and 25 mg packet was prescribed on 2/2/2023 but was not included on the Centrally Stored Medication Record (LIC622). Documentation reviewed dated 2/28/2023 notes the doctor was not able to send a refill request due to insurance reasons and C1 last took this medication on 3/4/2023. There was no documentation on file that C1 would be okay without taking this medication while the refill was pending. Facility was asked to schedule an appointment with C1's specialist and did later obtain a scheduled appointment in August 2023.

Medication errors were also discovered for client (C2). Specifically, an order was observed for a MultiVitamin; however, there was no medication observed to be available to administer to C2, and the medication was not listed on either the LIC622 or Medication Administration Record (MAR).