Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Nick Fierro, Administrator

Today's visit was in response to Licensee’s self-reported AWOL and a self report for a medication error and a self harm incident for Clients 1,2, and 3 (C1, C2, C3), received at the CCLD San Diego Regional Office on 06/22/2026, 06/23/2026 and 06/24/2026.

[See LIC 811 Confidential Names List for a description of C1-C3]. Per the reports, there was a report was for a self harm incident on 06/15/2026, a report for a medication error on 06/22/2026 and a report for a client that went AWOL on 06/23/2026.

The AWOL took place and a missing persons report was filed on 06/23/2026. Interviews revealed that C1 returned on 06/25/2026. The facility followed their absentee notification plan.

The medication error occurred and the staff immediately notified the administrator and they notified the on call pharmacist and they were advised to withhold the bedtime medication for one day for C2. They monitored the client for any side effects for the rest of the night. There were no signs of distress or physical symptoms resulted.

The last report occurred on 06/15/2026 when a client tried to commit self harm. C3 told staff that they had consumed alcohol. The on-duty Case Aide, intervened during the call to 911 that the client made to assist the dispatcher due to communication difficulties and provided the clients mental health history. EMS did not respond to the initial phone call, and according to staff the client did not appear to be in any distress and went to bed.