Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa met with Juan Andres, Program Director; Elizabeth Hall, Administrator; Amber Salazar, Executive Director; and Katrina Brass, QIC for a Case Management- Incident Inspection, on 10/21/2021 at approximately 2:00 PM. The inspection is being conducted to review clients' incident reports to determine the safety of medication administration at the facility.

LPA conducted an incident report review of two clients medication errors; per conferencing with administration and review of medication records, the licensee did not ensure that Client C1 was administered the correct medication on 9/16/2021, C1's pharmacist was notified. In addition, another incident report on 09/23/2021, indicated that staff did not administer a medication to C2, due to staff misreading medication record.

During today's visit, LPA met with facility staff and went through a review of medication records, protocols, policies and incident reports. While reviewing, LPA learned of 2 new medication errors which the facility is still reviewing and will be reported to Community Care Licensing within the required time frame. The facility was previously cited (1/12/21) for failure to issue medications as prescribed and for failure to report incidents.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.