Facility Evaluation Report

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Assistant Program Administrator Zachary Mccormick to discuss the purpose of the visit. Program Administrator Adedapo Ajibade arrived later during the visit.

Today's visit is in response to the self reported medication error for Client 1 (C1) on 02/13/2026. Staff interviews and facility records showed that an unanticipated interruption occurred during the medication administration for C1. This caused three of C1's prescriptions to be inadvertently skipped. Facility staff became aware of the missed administration during shift change. C1's physician was contacted and it was approved for C1 to receive the medication outside of the required window, at 2:15pm this same day. C1 did not suffer adverse effects from the delayed medication administration. The facility updated their medication procedures to include this type of scenario in the future to prevent this situation from occurring again. The staff involved with the medication error was retrained, including three fidelity checks for medication administration before administering again.

LPA conducted a wellness check at the facility; no health or safety issues were identified. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Program Administrator Adedapo Ajibade , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.