Facility Evaluation Report

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

The purpose of today’s visit is to address two self-reported incidents reported to CCL on 12/12/2022 and 1/25/2023.

Incident #1: CCL received an incident report stating on 12/7/2022, Staff 1 (S1) discovered a partially dissolved pill of Clonazepam 0.5 mg under the facility couch. Incident report states S1 did not follow medication administration protocol and must not have stayed with Client for 5-10 minutes to ensure Client has swallowed the medication.

Incident #2 : On 1/25/2023, CCL received an incident report stating Client 1 (C1) approached Staff 2 (S2) and Program Administrator Antonela Milito with two pills that looked old and chewed. The date the pills were to be consumed is unclear but presumed to have occurred on 1/23/2023 because Staff 3 (S3), on-call staff, did not follow the process correctly. In November 2022, medication procedure changed to include two staff watch clients take their meds. On 1/23/2023, S3 was observed not following the process during the evening med pass. Incident report states S3 was given immediate feedback however a supervisor was not there at bedtime to monitor the medication distribution.

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 during the visit. Civil penalty issued.