Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 10/31/23. LPA was greeted and met by Staff Aidelada Villela at the front door. LPA introduced self and stated purpose of the visit.

On 10/26/23, Administrator performed a medication audit and noticed that medication had not been given to one client from 10/20/23-10/25/23 due to staff marking medication as discontinued on MARS and not checking for back-up supply.

During today's visit, LPA met with Licensee in the office who later arrived to discuss the incident and surrounding events. LPA interviewed and reviewed records. During interview and records review, it was discovered that medication training was given to staff on 11/15/23 and the staff with the medication error resigned on 10/27/23.

No deficiency was issued during this visit. An exit interview was conducted where this report LIC809 was reviewed, discussed and then provided to Licensee, Erika Carr.