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 Executive Director Sam El Rabaa.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 01/29/2024). According to the LIC624, on 01/21/2024, it was observed that Resident #1 (R1) had three (3) transdermal medication patches on their skin/body simultaneously, instead of just the prescribed one (1) patch at a time. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. This incident did not result in any adverse health consequence for R1.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe and at their baseline level of functioning. LPA interviewed pertinent facility staff and an outside witness. LPA collected copies of and reviewed pertinent care and personnel records. LPA also inspected the box and pharmacy label for R1’s medicated patch, and reviewed the published usage guidance from the manufacturer for said patch.

Per their latest LIC602 Physician’s Report (dated 09/21/2022), R1 was diagnosed with Dementia and Parkinson’s Disease. R1’s doctor determined that R1 was “confused/disoriented,” required staff assistance with taking their prescribed medications, and required staff assistance with bathing and dressing, among other personal care needs. Manager interview corroborated these points. LPA was unable to qualify R1 as a reliable historian/interviewee for this case, due to R1’s baseline cognitive impairment.