Facility Evaluation Report

At approximately 12:50 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Administrator, Christina The. The facility submitted one (1) Incident Report (IR) for Client 1 (C1) for a medication error.

The IR stated that on Sunday, 3/8/2026 at approximately 8:00 PM during the evening medication pass one (1) prescribed medication was not given to client C1 in error. The medication error was discovered the following morning during the morning medication count by staff member S2. The facility's policy is to have a second (2nd) staff member count the medications at the end of each shift. This medication distribution accuracy check did not occur per facility policy on the evening of 3/8/2026. Instead, the staff member (S1), who committed the medication error signed off on the medication distribution accuracy check. The following morning (Monday, 3/9/2026) when staff member S2 discovered the error the facility contacted client C1's Primary Care Provider at Santa Rosa Community Health and monitored the vital signs of client C1. There was no adverse effect noted for client C1. The facility will be cited for this medication error.

As part of the Plan of Correction (POC) all facility staff members responsible for distributing medications will undergo training in Medication Accountability.

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, LIC-811 Confidential Names and Appeal Rights discussed and provided to Administrator The. Signature on form confirms receipt of documents.