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 Chief Executive Officer Debra Emerson and Assistant Director of Programming Mark Louis Fisher.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/29/2023). According to the SIR: During a daytime community outing on 09/21/2023, errors by Staff #1 (S1) led to Client #1 (C1) not receiving their as-needed (PRN) medications according to how they were prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on C1, finding that they were safe, alert, and participating in an activity. LPA also reviewed pertinent care records and interviewed relevant staff.

According to care records: C1 was diagnosed with Profound Intellectual Disability and Mild Cerebral Palsy (among other diagnoses). Manager and staff interviews unanimously confirmed that C1 required staff assistance with storing and taking their prescribed medications.

Staff interviews and care and personnel records showed: Before taking clients on daytime outings, staff are required to place clients’ routine medications in blue pouches, and then the clients’ PRN medications in red pouches. This color-coding practice is meant to aid the staff in medication administration accuracy. Leading up to the 09/21/2023 outing, Staff #2 (S2) placed C1’s routine and PRN medications alike into a single blue pouch, and then handed this pouch to S1 to take with them. During the outing itself, C1 did not exhibit signs, symptoms, or criteria to justify/warrant receiving their PRN medications. Nonetheless, S1 mistakenly gave C1 doses of two (2) as-needed PRN medication, as if these were routine medications. S1 did not read and verify the labels which were affixed to the medication bottles before giving said medications to C1. CONTINUED ON LIC 809-C]