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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804201
Report Date: 01/28/2025
Date Signed: 01/28/2025 08:52:24 AM

Document Has Been Signed on 01/28/2025 08:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HYPERION CRTFFACILITY NUMBER:
126804201
ADMINISTRATOR/
DIRECTOR:		GILBERT, DAVIDFACILITY TYPE:
772
ADDRESS:528 N STTELEPHONE:
(530) 300-4238
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 10CENSUS: 5DATE:
01/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Alana RobergTIME VISIT/
INSPECTION COMPLETED:
09:00 AM
NARRATIVE
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a medication error reported by the facility. LPA met with House Manager Alana Roberg. A summary of the incident revealed an individual was prescribed a liquid medication and the pharmacy was having difficulty filling the prescription. Approximately 4 days later, the medication was delivered to the facility and logged in as received. The staff logging the medication failed to notify the house manager and the medication was not entered into the Medication Administration Record, (MAR). The medication was present at the facility for approximately 6 days before it was brought to the attention of the House Manager. The individual did not receive the medication during this time. House manager conducted retraining for all staff on medication procedures to ensure this incident is not repeated.


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Alana Roberg and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 08:52 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 01/28/2025 at 08:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HYPERION CRTF
FACILITY NUMBER: 126804201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
81075(b)

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81075 Health-Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on records reviewed, Client did not received medication ordered by the
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House manager conducted retraining for all staff on medication procedures. POC Cleared at time of visit.
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Physician. This poses an immediate Health Safety or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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