Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management inspection and met with Shemar Lewis (Associate Director) and Kiarra Cooper (Lead Staff). The visit is due to incident report regarding medication error submitted to Community Care Licensing (CCL) on 3/12/25.

Per incident report, on 3/11/25 at approximately 5:00 pm while grave shift was conducting medication count, it was found that client (C1) was distributed Metoprolol 50 mg instead of Metformin 500 mg. Staff contacted pharmacy who informed C1 should be fine but to check blood pressure in the morning as it may be lower than usual and to pass the Metformin medication as usual in the morning.

Case Management Report of 11/12/2024 for medication errors indicate, QuickMAR computerized system appeared to be the issue due to system is not populating medications correctly, so the facility will go back to use paper MARs where two staff have to sign and verify current medication on hand along with prescribed dosage and reach out to lead staff for clarifications if needed. At today’s visit Associate Dir. indicated they did not continue with the change to paper and just conducted additional training. Now if Qmar is down the 2 staff (a verifier & a passer) will look at the paper to insure physician’s orders of medication will be followed. Behavior Health Tech processing all medication currently. S1 & S2 not currently passing meds until fully retrained.

***Civil Penalty assessed in the amount of $250 due to repeat citation of same regulation 80075(b)(5)(B) in less than a 12 month period. 11/12/2024

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.