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 Lead BSP Trevor Sparkman and Assistant Program Director Cruz Mora.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 02/19/2024. According to the SIR, during the morning of 02/16/2024, an error by staff led to Client #1 (C1) not receiving one (1) dose of one (1) of their prescribed medicines. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The missed dose 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, verifying that they were safe. LPA collected copies of and reviewed pertinent records. LPA also interviewed relevant staff.

Per their latest LIC602 Physician’s Report (dated 10/02/2023), C1 was diagnosed with Mild Intellectual Disability and Autistic Disorder (among other diagnoses) and their doctor determined that C1 required staff assistance with taking their prescribed medications.

Based on LPA observation: The medication involved in the above incident was a small round pill to be given once per day. The pills were stored inside a “blister pack,” which is an approved, labeled, and numbered card dispensed direct from the pharmacy. Within the blister pack card, each individual pill sits inside its own plastic bubble, and each bubble is backed with a foil lining. When staff push/depress the bubble with their finger(s), the foil lining is meant to break, allowing the pill to fully drop/come out of the card.