Facility Evaluation Report

On 8/6/2024, Licensing Program Analysts (LPAs) Grace Donato & Kiran Jain conducted an unannounced case management visit. LPA met with Administrator, Kris Bartolome and Program Manager (PM) Mary Beth Sandoval followed after. LPA explained the purpose of the visit.

On 7/23/24, LPA Donato received an incident report during desk duty. The incident is about a resident (R1) who took the wrong medication during a medication pass. The medication tray with all of the clients' dinner medications was on the desk between R1 and the counselor on duty (S1). At that moment, S1, was distracted by another client and a phone call and did not see R1 reach in to take dinner medications. R1 left the office and another client came into the office to take their medications. S1, then realized that the medications for this client were not in their cup. The staff looked through all the dinner medications and realized that R1's were still there and that R1 mav have taken the other client's medications by mistake.

PM was made aware. Staff called Psychiatric Emergency Services (PES) and R1 was sent to hospital for observation. R1 came back the following day and is ok. R1 reported to be feeling fine and had a follow up appointment. PM did a retraining for S1 regarding medication.

Discharge papers were received and in-service training log will be emailed/faxed to LPAs.

Report is reviewed and a copy is provided.