Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Justin Griggs. LPA also met with Quality Assurance Manager Morgan Davis, who arrived later during the visit.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 01-17-2023. According to the SIR, on the evening of 01-13-2023, an error by Staff #1 (S1) led to Client #1 (C1) not receiving one (1) of their medicines as prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. Licensee wrote they temporarily removed S1 from medication duties until they could be retrained, and that the missed dose did not cause any adverse health consequence for C1.

During today’s visit, LPA performed a facility tour and welfare check on the clients who were present, verifying that C1 was indeed unharmed/uninjured. LPA also interviewed relevant staff and collected pertinent records.

Per their latest LIC602 Physician’s Report, C1's was diagnosed with "severe intellectual disability" and they required staff assistance with taking their prescribed medications.

Due to their baseline limited verbal skills, C1 was not able to participate as a reliable interviewee.

According to staff interview and corroborated by audit records from San Diego Regional Center (SDRC): during the above incident, S1 gave C1 only half of their prescribed dose for one (1) medicine. Licensee arranged for their nurse manager to retrain S1 following the incident.