Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection at the facility today and met with Administrator Judi Flickner. The purpose of today's inspection is to follow up on a self-reported incident which occurred on 12/04/2024. During today's visit there were no clients present.

On 12/05/2024, the Regional Office received an Incident Report (IR), reporting that on 12/04/2024 at approximately 11:51 a.m., Staff 1 (S1) gave Client 1 (C1) Klonopin 1MG which belonged to another client during an outing. C1 was returned to the day program where vitals were taken and normal. It was further reported that the DP was instructed by C1's care home, who consulted their MD, to monitor C1.

On 12/05/2025, LPA Cortez contacted the programs Administrator to request additional information over the phone. Administrator Judith Flickner advised the LPA that C1 was doing well and that other than being sleepy and groggy the day of the incident there were no other side effects. The DP informed C1's care home of the incident and they consulted with the pharmacist, who let them know there should be no concern and to monitor the client. The Administrator further reported that S1 was disciplined and would receive medication re-training.

During today's visit the LPA interviewed the Administrator and one staff. The Administrator revealed that C1 was back to normal the next morning and is doing fine. S1 received training and proof had been submitted to licensing, however DP did not notify C1's physician of the incident. The Administrator further revealed that they have now implemented that a nurse will be going with the clients during an outing.

The following deficiencies were cited (See LIC 809-D.) from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Report and appeal rights were provided.