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 Randal Newton.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 01/17/2024. According to the LIC624: during the morning of 01/17/2024, an error by staff led to Resident #1 (R1) receiving double (i.e., twice as much) of their prescribed dose for each of eight (8) of their medications. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. The overdoses 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 well. LPA collected copies of and reviewed pertinent care and personnel records. LPA also interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/05/2022), R1 was able to administer their own prescription medications. However, according to the latest Service Plan (dated 09/23/2023) which Licensee prepared on R1, they required assistance with medication management. Manager interview also confirmed that R1 now had mild memory impairment and was paying Licensee to help them take their medications during the time of the incident.