Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela conducted an unannounced case management inspection and met with Selene Cruz-Astroga, Licensee. The purpose of this case management inspection is to follow up on an incident which was self reported to LPA on 08/20/2021 by telephone. An incident report was submitted to Community Care Licensing (CCL) on 08/23/2021.

The following was reported: On 08/20/2021 at approximately 8:30 AM Staff (S1) was preparing medication for the clients. S1 prepared Client (C1)'s medication in a medication cup with C1's initials on the bottom of the cup. S1 left the medication cup on the counter to grab a glass of water for C1. S1 then gave C1's medication (2 medications) to Client (C2) by mistake. Staff realized the mistake immediately and contacted Paradise Home's Nurse Consultant, who advised to contact C2's medical physician. Staff contacted C2's psychiatrist who advised C2 be taken to urgent care. C2 did not display an immediate reaction to the medication. C2 was taken to urgent care at North Bay Medical at approximately 9:00 AM and was discharged at 10:30 AM due to no signs of toxic effect. C2's hospital discharge paperwork (copy provided to CCL on 08/23/2021) indicated C2 was evaluated and treated for "Accidental Ingestion: Nontoxic (Adult)". Paradise Home staff were advised by C2's psychiatrist to continue C2's medication for the day. North Bay Medical Center discharge notes stated to hold C2's medication for the rest of the day. Staff followed NBMC's written report and held C2's medications for the day.

During today's inspection LPA reviewed S1's initial medication training and DSP training (which includes medication training). Licensee provided re-training on medication on 08/20/2021 for S1 and 2 staff who were present during the incident. Licensee provided re-training on medication to all staff on 08/21/2021. Staff will focus on their medication set-up, staff communication/reminders, and limit distractions.

In addition to the self-reported incident, immediate action taken, and medication training provided, S1 was suspended for 3 days.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Selene Cruz-Astroga, whose signature below confirms receipt of report.