Facility Evaluation Report

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Stacy Singleton, and was later joined by Administrator Ashlee Menefee.

Today's visit was in response to a Special Incident Report (SIR), which licensee self submitted to the CCLD San Diego Regional Office on 2/19/26. According to the SIR, the incorrect dosage was administered to Client #1 (C1) from 2/6/26 through 2/17/26. [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. LPA interviewed staff and reviewed relevant records. According to staff interview, the medication error was realized when doing a review of the Medication Administration Record (MAR). C1 was taken to their primary care physician for assessment. No adverse symptoms were observed by the physician and the physician ordered for the medication regime to resume on 2/20/26.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator.

An exit interview was conducted with Administrator Ashlee Menefee, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.