Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted a case management visit at the Day Program (DP) regarding two self-reported incidents that occurred on 02/10/2025 and 02/21/2025. The LPA met with the DP's supervisor Jinica Destrampe and explained the reason for the visit. At the time the LPA arrived the clients were leaving the DP for the day. Area Director Leah Kolbeck was present during today's visit as well.

It was reported that on 02/10/2025, Staff 1 (S1) lost Client 1's (C1) back pack with their Medication Administration Record (MAR), which contains C1's name, gender, birth date, medications, physician's name and pharmacy name.

It was also reported that on 02/21/2025, Client 2 (C2) was picked up early at 11:30 a.m. due to having a terrible cough. When C2 got picked up, their family member realized they needed changing and went back inside to change the client. DP's Supervisor assisted in changing C2. Family member mentioned to Supervisor that C2's skin is easily irritated and both of them observed a small irritated spot on C2. C2's Staff 2 (S2) for that day was informed C2 needed to be changed, and S2 apologized for their oversight.

During today's visit the LPA conducted two (2) staff interviews and a file review. Interview with S1 revealed that they lost C1's personal back pack with their MAR. Interview with the DP's supervisor revealed that S2 is not a regular staff, did not read C2's file and therefore was not aware that C2 needed to be changed as part of their care needs. Furthermore, C2 went from 8:30 a.m. to 11:30 a.m. without being changed. File review revealed that C2 needs to be toileted when they get to the DP, after lunch and before they get on the bus and that they have very sensitive skin and will break out in a rash if they are not changed properly. Furthermore, File review revealed that S2 is not associated to the DP. S2 got associated during the visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted. A copy of the report and appeal rights were provided.