Facility Evaluation Report

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility today. LPA met with Jennifer Farley, Program Director and Antonela Milito, Program Manager.

The purpose of today’s visit is to address two self-reported incidents reported to CCL on 11/28/2022 and 11/29/2022.

Incident #1 : Program Administrator reported Client 1 (C1) is prescribed one (1) dose of two (2) tablets of Escitalopram 20 mg at 8:00 am each morning. On 11/26/2022, Staff discovered one tablet of Escitalopram 10 mg remained in the bubble pack. It was determined that C1 was not given the full 20 mg dosage and was only administered one (1) tablet of the Escitalopram on 11/21/2022 at approximately 8:00 am.

Incident report states Staff 1 (S1) and Staff 2 (S2) will be provided medication re-training and second medication check procedure has been changed to be conducted before medications are administered rather than after the medications are administered.

Incident #2 : Client 2 (C2) is prescribed a daily dosage at 12:00 pm of Chlorpromazine 50 mg; Hydroxyzine PAM 25 mg; Quetiapine Fumarate 200 mg; and Clonazepam 0.5 mg. On 11/28/2022, Antonella Milito, Program Manager became distracted and did not administer C2’s 12:00 pm prescribed medications. Incident report states Program Manager will be provided medication re-training.

During today’s visit, LPA obtained copies of “Client at a Glance” (Client’s face sheet including contact information), Doctor’s orders for medications, and Medication Accounting Record (MAR) for C1 and C2. LPA toured the facility with Program Manager and reviewed medications for C1 and C2.

LPA conducted an interview with Program Administrator on 12/6/2022 starting at 1:38 pm. Based on record review and interview(s) conducted, it was determined that the licensee did not ensure C1 and C2 were assisted with their medication(s) as prescribed.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).

Exit interview conducted. Copy of report and appeal rights issued via email.