Facility Evaluation Report

At approximately 11:15 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 Wednesday, 4/8/2026 at approximately 5:30 AM staff member S2 found a pill on the ground. Staff member S2 cross referenced medications and determined that the medication was for client C1 and that the medication is normally given to C1 during the evening medication pass. The medication found was from the evening medication pass on Tuesday 4/7/2026. Staff member S2 immediately called House Manager Doyle. The facility notified client C1's emergency contact person and the doctor that prescribed the medication. Client C1's vital signs were closely monitored and C1's vital signs remained at baseline. 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) evening & nighttime facility staff members responsible for distributing medications will undergo additional training in Medication Distribution & Accountability. Additionally, the staff member (staff member S1) distributing medications on the evening of 4/7/2026 has been removed from medication administration duties by the facility Administrator.

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.