Facility Evaluation Report, 10/25/2023 — Community Solutions Crisis Residential, Morgan Hill CA

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Program Director, Matthew Miao. The purpose of the visit is to follow-up on an incident report the Department received regarding a medication error at the facility that occurred on 08/05/2023.

On 08/11/2023, the Department received an incident report regarding a medication error for resident (R1) which resulted in R1 missing one medication. Based on interview, R1 missed a medication because staff (S1) became distracted when trying to locate another one of R1's medications. S1 ended up not dispensing one of R1's medications but documented the administration on the medication count sheet. It was later found during the NOC shift's routine medication check, that one of R1's medications was missed. After the incident, the facility met with S1 one-to-one to review what happened and review the medication procedures/process to prevent future mistakes. S1 was also advised to focus on the current medication before moving onto the next. The facility decided to reduce the number of hours S1 works in the medication room. R1 was monitored throughout the day and observed to be within baseline. R1's doctor was informed of the incident. Based on the facility’s compliance history, the Department had conducted a case management visit on 04/05/2023 regarding the facility's frequent medication errors. Upon investigation, it was found the medication error conducted on 08/05/2023 was conducted by the same staff (S1) from previous incidents.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.

A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC. A plan of correction was developed with Program Director, Matthew Miao. This report was reviewed with Program Director, Matthew Miao and a copy of the report and appeal rights was provided.