Facility Evaluation Report, 04/05/2023 — Community Solutions Crisis Residential, Morgan Hill CA

Licensing Program Analysts (LPA) Christine Dolores and Manuel Monter arrived unannounced to conduct a case management - incident visit. LPAs met with Program Supervisor, Angelica Suud and Administrator, Jennifer Nguyen.

On 02/01/23, 02/02/23, 02/11/23, and 03/11/23 the Department received incident reports regarding medication errors at the facility. From 02/01/23 - 02/02/23, a client's (C1) was given wrong medication two days in a row. On 02/11/23, client (C1) was given double dose of medication at once. On 03/11/23, client (C2) was not given a medication during a medication pass. Client's medical professionals were notified of the incidents and monitored for any signs and symptoms.

After the incidents in February 2023, the facility had provided an in-service training to staff on the topic of MedRoom procedures. An in-service training was provided twice in the month of February 2023 to include one in-depth training on MedRoom procedures. During visit, LPAs reviewed and obtained the in-service training documentation's which included the date, length of course, participants signature, training topics, and instructor. LPAs also reviewed the facility's MedRoom procedures with staff (S1) who is a licensed professional and responsible for providing medication training. Staff (S2) was also present during the demonstration. LPAs did not observe concerns regarding the facility's MedRoom procedures.

During visit, LPAs toured the facility to include the backyard, resident rooms, and common areas. LPA Dolores interviewed 3 staff members (S1 - S3) regarding the medication errors. Based on interview, S1 - S2 stated medication errors could be due attributed to staff "rushing" through the process. The following documents were reviewed and obtained to include 3 staffs (S4 - S6) annual training records and facility correspondences.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Jennifer Nguyen and a copy of the report and appeals rights were provided.