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 Administrator Cherifer Manipon and Assistant Administrator Cynthia Ruiz.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 08/07/2023. According to the SIR, during the evening of 08-02-2023, an error by Staff #1 (S1) led to Client #1 (C1) receiving a double/extra dose of one of their prescribed medications. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The overdose did not result in any adverse health consequence for C1.

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

Per their latest LIC602 Physician’s Report, C1 had an “autism spectrum” diagnosis and their doctor determined that C1 required staff assistance with storing and taking their prescribed medications. Due to their baseline intellectual disability, C1 was not able to participate as a reliable historian regarding the incident.

Records and staff interviews showed: S1 quickly recognized their medication error, which was timely reported to C1’s prescribing physician and the San Diego Regional Center (SDRC). Facility staff continued to observe C1, per physician instruction, and C1 did not develop adverse health symptoms. Following the incident, Licensee temporarily removed S1 from medication pass duties until they could be retrained by a Registered Nurse. S1 underwent retraining, to include skills validation, before they were reinstated in medication pass duties.