Facility Evaluation Report

At approximately 12:05 PM, Licensing Program Analysts (LPAs) Robert Frank and Elias Magdaleno arrived unannounced to conduct a Case Management inspection and met with Administrator, Emiley Midyette. The facility submitted two (2) Incident Reports (IRs) for Client 1 (C1) for a medication error.

The IR stated that on Friday, 5/9/2025 C1 self administered AM medications prescribed for a different client. The facility contacted the doctor at a Crisis Stabilization Unit (CSU) who instructed C1 to take her prescribed AM medications as usual. On a second (2nd) IR also submitted that on the same day, 5/9/2025, C1 was taken to the hospital due to a change of condition possibly caused by the medication error. C1 was later discharged from the hospital and returned to the facility the same day, 5/9/2025, with no new instructions. The facility monitored C1 for any further change of condition post discharge. C1 was functioning at baseline condition after discharge.

AD Midyette stated that the staff member (S1) who was administering the medication was distracted by a visitor and was not monitoring C1 when the wrong medications were ingested. The staff member S1's employment was terminated.

The facility will be cited for this deficiency. On 5/14/2025 all facility staff members underwent Medication Administration Training. As such, this deficiency will be cleared during this visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Midyette. Signature on form confirms receipt of documents.