Facility Evaluation Report

Licensing Program Analyst (LPA) Esther conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250807110633 ). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation. Upon arrival, LPA met with Office Manager Nancy Garcia and explained the reason for the visit. Progam Director Nicole Lomeli was not able to be present during today's visit. Entrance interview conducted.

During the investigation of Complaint Control #29-AS-20250807110633 the following deficiency was observed: The LPA noted that the facility failed to report medication errors to Community Care Licensing (CCL).

On 11/18/23, Client 2 (C2) received a double dose of Adderall (60mg total). The error occurred because the NOC shift nurse administered the morning dose but failed to record it in the narcotic binder. Consequently, a Mental Health Technician (MHT) administered a second 30mg dose later that morning. On 03/16/25, Client 3 (C3) was administered Suboxone 12-4mg without a current order. C3 was prescribed Subutex, but staff substituted Suboxone from existing stock because the client had previously been on that medication.

The staff reported both incidents to their superiors and Director of Nursing, and was documented with the facility, but not reported to CCL.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator is informed that failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.