Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with outgoing Executive Director Ashley Marcellus and Director of Resident Care Services Elizabeth Smith. LPA also met with incoming Executive Director Wesley Lavender later during the visit.

Today's visit was in response to two (2) LIC624 Incident Reports, which Licensee self-submitted to the CCLD San Diego Regional Office (both were received on 01/12/2024). According to the first LIC624: during the evening of 01/06/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving an overdose of one (1) of their prescribed medications. [See LIC811 Confidential Names List for a description of select person identifiers used.] According to the second LIC624: during the evening of 01/09/2024, an error by S1 led to Resident #2 (R2) receiving medicine which was not prescribed to them [the medicine was instead prescribed to Resident #3 (R3)]. The above incidents did not result in any adverse health consequences to either R1 or R2.

During today’s visit, LPA briefly toured the facility and performed a welfare check on both R1 and R2, verifying that both were safe. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/09/2019), R1 was diagnosed with Dementia, and their doctor determined that R1 required staff assistance with taking their prescribed medications. According to their latest LIC602 Physician’s Report (dated 01/24/2023), R2 was diagnosed with Mild Cognitive Impairment (MCI), and their doctor determined that they required staff assistance with taking their prescribed medications. Manager interview confirmed that both R1 and R2 were on paid medication assistance service with the Licensee during the above incidents.