Facility Evaluation Report

Licensing Program Analyst (LPA) Nakagawa conducted an unannounced case management inspection and met with Administrator Watson The purpose of this case management inspection is to follow up on two (2) self reported incidents submitted to Community Care Licensing (CCL) on 03/06/23 and 04/10/23..

On 02/27/23 Client (C1) received the wrong dosag e of a prescribed medication within a 24 hour period. Per the incident report, staff failed to review the dosage and time of dosage and client was over-medicated. On 04/07/23 Client (C2) received the wrong dosage of prescribed medication and was under-medicated.

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 (Medication Administration Record) MAR for all staff to review prior to medication administration. Additional staff training has been on-going, including using the buddy-pass system to ensure staff are following all procedures correctly.

***Civil penalties in the amount of $250.00 are being assessed due to repeat violations in the past 12 months for regulation 81075(b) previously cited on 6/17/2022.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.