Facility Evaluation Report

Licensing Program Analyst (LPA) Eryn Kane conducted an unannounced Case Management – Incident visit. LPA Kane was welcomed, identified herself, and explained the purpose of the visit to Program Manager Valerie Davis. Director of Program Development Kim Keane and Senior Manager Administrator Tina Quinagon later joined the discussion.

The visit was conducted in response to a licensee self-reported medication error. Two Unusual Incident Reports were received at the CCLD San Diego Regional Office on 7/3/26. [See LIC 811 Confidential Names List for resident descriptions.] According to the reports, Client 1 (C1) received only half of their prescribed supplements during the period of 6/15/26–7/1/26. In addition, on 7/1/26, C1 did not receive their prescribed dose of medication at the scheduled time.

During the visit, LPA Kane interviewed staff and reviewed documentation related to the incident. Staff stated that a recent change in pharmacies and medication packaging contributed to the errors, which were identified during a self-administered medication audit. Staff reported that corrective actions were taken immediately, including notifying C1’s physician and Licensing and conducting medication training for staff.

One deficiency was cited in accordance with California Code of Regulations, Title 22. (Refer to the attached LIC 809-D.) A Plan of Correction was developed jointly with the Licensee.

An exit interview was conducted with Program Manager Valerie Davis, whose signature below confirms receipt of this report, the LIC 811, and the Licensee Rights (LIC 9058 01/16).