Facility Evaluation Report

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Direct Support Professional (DSP) Roxana Rios, to discuss the purpose of the visit.

Today's visit is in response to the self reported medication errors for Client 1 (C1) (see LIC811 Confidential List of Names) received on February 28, 2025 and March 6, 2025. It was reported on February 28, 2025 Staff 1 (S1) administered the wrong nasal spray inhaler to C1. One being the "daily dose" nasal spray and the other being the "PRN" nasal spray. The correct nasal spray was administered to C1 an hour later without incident It was reported on March 6 2025 that C1 was given their GERD medication by Staff 2 (S2) that fell from C1's lips to the floor. Both S2 and C1 attempted to locate the medication, but it was not found. S1 had provided C1 with the last available pill from the cycle. The pharmacy was called and a replacement pill was to be received on March 6, 2025. A medication training was conducted by Administrator on March 1, 2025 that S1 attended.

Records review of C1's Physician's Report revealed that C1 has a primary diagnosis of mild intellectual development disorder and although C1 is able to administer and store their medications the facility is required to store and dispense the medication to C1.

LPA interviewed staff and collected records.. No deficiencies were cited or observed on this date.

An exit interview was conducted with Roxana Rios who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.