Facility Evaluation Report

Licensing Program Analyst Leibert arrived unannounced and met with Jessica Stillman to discuss three incidents involving medication errors. The errors occurred on May 21, 2023 and May 06, and June 28, 2023. The errors involved wrong dose amounts and wrong time of administration. None of the errors resulted in any health complications for the clients. Subsequent to the errors discovery, Administration provided additional training to the staff who administer medications to the clients.

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.