Facility Evaluation Report

At approximately 11:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with House Manager (HM), Tamariah Doyle. The facility submitted one (1) Incident Report (IR) for Client 1 (C1) for a medication error.

The IR stated that on Friday 3/20/2026 during the 7:00 PM medication distribution, client C1 accidentally knocked over the pill cup containing their medications prior to taking any medications in the cup. Staff member S1 caught one (1) pill in their hand and put it back in the cup. Staff member S1 did not realize that another pill had fallen on the ground. Staff member S1 and the Medication Checker, staff member S2, did not audit the medications in the cup against the Medication Administration Record (MAR). At approximately 10:23 PM on the same day, 3/20/2026 staff member S3 found the pill on the floor and immediately notified HM Doyle. Client C1's vital signs were closely monitored and C1's vital signs remained at baseline. The facility notified client C1's Primary Care Physician and C1's emergency contact person. Additionally, the facility contacted it's consulting Nurse Practitioner. 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 Distribution & 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 HM Doyle. Signature on form confirms receipt of documents.