Facility Evaluation Report

On 3/27/24, at 3pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit. LPA initially met with the staff on duty and explained the purpose of the visit. The facility administrator, Pearl Ofodire, was notified and made aware of the visit and arrived shortly after. During this visit, present were four clients in care with two staff on duty.

During today's visit, LPA conducted a facility observation and staff interview. LPA observed clients in care doing their own activities. One client was sitting on the massage chair while the other two was watching TV. During room inspection, one client was in their bed lying down and watching a movie. Per interview with staff on duty, clients just arrived from their day program and just finished their shower. Per staff on duty, they had plan to go for a walk today but it is raining at this time. Staff on duty added they will do alternative activities of their choosing.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review conducted on 2/22/24 by Alta California Regional Center (ACRC) representatives. The Department was made aware that a medication error was found substantiated during a medication review. ACRC representatives noted the absence of staff signatures on 1 of 4 clients’ Medication Administration Record (MAR) from the morning (7am) of 2/22/24. ACRC representatives also noted that a review of 1 of 4 clients' MAR revealed that one medication was incorrectly inputted in the MAR. Per review of the client's medication stated a different dosage compare to what was inputted in the MAR.

The Department was also made aware that this facility was found substantial inadequacies during personnel record review on 2/22/24. ACRC representatives also conducted personnel records and found that two staff were missing documents that record their required training.