Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to review the circumstances surrounding an incident report submitted to Community Care Licensing . At the time of LPA's arrival, there were 3 clients, with a fourth expected later that day. There were 2 staff and 2 administrators on site as well.

The self-reported incident occurred on May 14, 2022 and involved a client receiving the wrong dosage of prescribed medication. Per the incident report, staff failed to review the dosage and client was under-medicated. The underdosage of medication was reported to Program Director and medical team.

LPA reviewed the facility's "Medication Protocol" with Program Director. Additional safeguards and precautions have been put in place. Staff meet at change of shift to review any medication changes with on-coming staff; med lists are included at the front of the MAR for all staff to review prior to medication administration. In addition, a nurse is being added to the staff several days a week, and a doctor from Yolo County will now be overseeing clients and their care, including their medications and prescriptions.

LPA is citing the facility for failure to assist a client with with self-administration of prescription medications.

Deficiencies are cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided.