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 Registered Nurse Jennifer Peters. LPA also met with Quality Assurance Manager Morgan Davis and Assistant Program Manager Mitch Blackwood, who arrived later during the visit.

Today's visit was in response to three (3) Special Incident Reports (SIRs) regarding medication errors, all involving Client #1 (C1), which licensee self-submitted to the CCLD San Diego Regional Office. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] According to the first and second SIRs (both received 02-22-2023): between 02/20/2023 and 02/21/2023, staff did not give to C1 (i.e., they missed) three (3) of four (4) doses of their prescribed eye drop medication. These errors were discovered via an internal self-audit. According to the third SIR (received 03/20/2023): Staff did not give to C1 (i.e., they missed) one (1) dose of their prescribed nebulizer medication on 03/17/2023. This error was also discovered via an internal self-audit. Per the SIRs: the above missed doses did not result in any adverse health consequence for C1.

During today’s visit, LPA performed a brief facility tour and attempted a welfare check on clients, but all four (4) clients (including C1) were off-site, either at doctor’s appointments or on recreational outings with staff. LPA interviewed pertinent staff and reviewed relevant records.

Per their latest LIC602 Physician’s Report, C1 was diagnosed with “mild intellectual disability” and required staff assistance with taking their prescribed medications. Manager interviews confirmed that C1 indeed needed staff help with taking their medications, and C1 was indeed unharmed/uninjured from these incidents.