Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management POC visit for a deficiency issued on 4/8/2025. LPA met with Staff S1 Ma Rose Dacoco. S1 called Administrator Naya Herrera. LPA spoke via phone with ADM and stated the purpose of the visit. ADM states she would not be present for the visit due to illness. ADM authorized S1 to sign on her behalf. S1 states there are 5 client and 2 staff.

On 4/8/2025 LPA Tarin conducted the facility's annual inspection. During review of Centrally Stored Medication and Destruction Records (CSMDRs) and medication, LPA observe d the facility is administering Medication M1 to C3 with an incorrect dosage that does not match the doctors prescription. A deficiency was issued and a Plan of Correction (POC) was developed with the ADM. ADM stated the facility will conduct staff training regarding medication administration and contact C3's physician. The POC was due on 4/9/2025. ADM submitted POC to the Department on 4/9/2025

LPA reviewed documentation of staff training conducted on 4/10/2025 to include medication administration. LPA spoke via phone with ADM. ADM states the facility will obtain an updated physician's report for C3 to include updated medications and submit to the Department by 4/25/2025.

LPA cleared the deficiency cited on 4/8/2025 and A Letter of Deficiency Citations Cleared was printed and provided to S1 during today's visit.

No deficiencies were cited during todays visit. An exit interview was conducted with S1 and a copy of this report was provided.