Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Morgan Ray (Program Director). LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on four incident report received at CCL on 7/6/22 involving all four Clients in care (C1, C2, C3 and C4). On 6/2/22 at around 9:00am Nurse Supervisor discovered that on 6/1/22 temporary staff (S1) who is a LVN from Nurse Registry did not assist four out of four clients with their prescribed medications between 11:00am to 7:00pm. Upon discovery of missed medications clients Physicians were notified and instructed to observe and monitor clients for any adverse reactions. Nurse Supervisor observed that medications were still in the medication containers and were not given to clients in care. S1 was terminated on 6/2/22 and Nurse Registry was notified about this incident.

During today's inspection, LPA was informed that S1 was a temporary staff who came to work for this facility

since the last weekend of May and did not receive training on medication management. Per Morgan, the facility has been conducting training to staff that pass out medications. However, the facility is not able to provide proof of staff training records for this year. LPA was also provided with staff schedule that reflects two staff (DSP/LVN) working between 5:30am-8:00am then clients do attend to day program during the day, two staff (DSP/LVN) between 12:00pm-2:00pm, two staff (DSP/LVN) between 2:00pm-8:00pm and one staff for NOC shift. Facility records (MARs) indicates that clients were provided with medications on 6/1/22. However, all recorded medications were found in their original container by Nurse Supervisor. According to Morgan, S1 had access to all clients medications and the reason why the clients were not assisted with their prescribed medications is unknown.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.