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 Assistant Program Director Cruz Mora.

Today's visit was in response to an incident report, which licensee self-submitted to the CCLD San Diego Regional Office on 12/11/2023. According to the report: During the evening of 11/26/2023, an error by staff led to Client #1 (C1) receiving only half of the prescribed dose for one (1) of their medicines. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

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

Per their latest LIC602 Physician’s Report (dated 07/21/2023), C1 was diagnosed with Autism Spectrum Disorder and required staff assistance with taking their prescribed medications.

Records and interviews showed: For one of their medicines, C1 was prescribed two (2) 500 mg tablets per day. During the 11/26/2023 incident, an error by Staff #1 (S1) led to C1 receiving only one (1) of these tablets, instead of two (2). C1 thus received only half their prescribed daily dose. This under-dose did not result in any adverse health consequence for C1.