Facility Evaluation Report, 08/14/2024 — 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 Manager, Angelica Suud.

The purpose of the visit was to address 6 medication errors that occurred on 02/22/24, 02/25/24, 06/14/24, 06/15/24, 06/23/24, 07/31/24. The medications errors were conducted by 5 different staff members. Based on interview, it was stated the facility implemented a new electronic system that was launched in June 2024 to reduce the amount of medication errors. In June 2024, the staff were fully trained on the use of the electronic system. It was stated that the staff members who have participated in the medication errors are talked to after every error. It was stated that all staff on the floor are trained on passing medications, however, 1 staff is scheduled to pass medications per shift. They try to keep the staff who is passing medication consistent throughout the weeks unless there is a call-out. Based on record review, the 5 out of 5 staff members are provided training on medications. The PD states medication training is assigned yearly for all staff.

The facility's plans to continue using the electronic system which has reduced a lot of the medication errors besides the error on 07/31. The facility will also continue group training on medications that is completed at least quarterly. The facility will continue tracking and monitoring staff who are prone to medication errors and take administrative actions, if necessary.

Documents were obtained to include 5 staff members training records, S1's written disciplinary action, and the facility schedule for June - July 2024.

A deficiency was 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. This report was reviewed with Program Manager, Angelica Suud and a copy of the report and appeal rights were provided.