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 Quality Assurance Manager Morgan Davis.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 09/28/2023. According to the SIR, during the evening of 09/25/2023, an error by Staff #1 (S1) led to Client #1 (C1) receiving only the half prescribed dose for one (1) of their medications. [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 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.

Care records and staff interviews showed: Licensee identified the medication error during a self-audit the next day on 09/26/2023. C1 did not experience any observable adverse symptoms from the underdose. C1’s physician and San Diego Regional Center were timely notified. 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.