134604232-10-13-2022-08-AS-VWIN-CK6TCJ-20221013143650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 134604232
Report Date: 10/02/2022
Date Signed: 10/13/2022 02:37:05 PM

Document Has Been Signed on 10/13/2022 02:37 PM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	JACKSON HOUSE EL CENTRO		FACILITY NUMBER:	134604232
ADMINISTRATOR:	CAROLINA NUNEZ-GARCIA		FACILITY TYPE:	772
ADDRESS:	2364 SOUTH 2ND STREET		TELEPHONE:	(760) 237-9769
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY: 16		CENSUS: 8	DATE:	10/02/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Carolina Nunez-Garcia, Program Director		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on a self- reported incident, received by Community Care Licensing on 10/2/22. LPA was granted entry into the facility by Program Director Carolina Nunez-Garcia, to whom LPA discussed the purpose of the visit. The facility self- reported a medication error involving three facility staff administering the incorrect prescription of medication to Client 1(C1). On 8/25/22, an incorrect prescription for Rifabutin 150 mg was submitted to the pharmacy by Staff 1 (S1), instead of Rifampin 300 mg. On 8/26/22, the medication Rifabutin 150 mg was received at the facility by Staff 2 (S2). The medication Rifabutin 150 mg was administered for the first time on 8/28/22, by Staff 2 (S2), and was continuously administered daily by S1, S2 and S3 (LIC 811 Confidential Names provided to Program Director) through 9/24/2022, instead of Rifampin 300 mg x 2. Per Sharon Simmons, Director of Nursing (DON), C1 did not experience any adverse effects from the Rifabutin. On 9/25/22, Sharon Simmons, Director of Nursing (DON) was notified by Staff 4 ( LIC 811 Confidential Names provided to Program Director) that the medication Rifabutin 150 mg had been dispensed to C1 instead Rifampin 300 mg. S4 verified that the label on the bottle of the Rifabutin 150 mg did not match the Medication Administration Record (MARS). DON spoke with C1 and they confirmed that they had been administered the medication daily. DON requested that S4 hold the medication because there was no coinciding medication order for Rifabutin. On 9/26/22, DON contacted Imperial County of Public Health, and spoke to a nurse (LIC 811 Confidential Names provided to Program Director) to verify medication regimen for Rifampin. It was confirmed that C1 should be taking Rifampin 300 mg x 2, and to restart the medication immediately. C1's Nurse Practitioner was contacted by DON.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACKSON HOUSE EL CENTRO	FACILITY NUMBER: 134604232
	VISIT DATE: 10/02/2022

NARRATIVE

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A review of records confirmed that S1, S2 and S3 received disciplinary counseling for failure to follow the standard Five Rights of Medication Administration. Training will be provided to all nurses and mental health technicians at the facility.

During today's visit, LPA Williamson toured the facility, interviewed staff, obtained documents and reviewed resident records and MARS. Interviews conducted revealed that the medication information in the MARS was correct, however the medication ordered was not the correct medication. Staff interviewed stated that Rifabutin 150 mg and Rifampin 300 mg are both red and similar in color. A review of the MARS confirmed that S1, S2 and S3 administered the incorrect prescription to C1, and not according to physician’s orders.

A deficiency is being cited pursuant to Title 22, Division 6, Chapter 2 of the California Code of Regulations on the attached LIC809D. An exit interview was conducted with Carolina Nunez-Garcia, Program Director and Sharon Simmons, Director of Nursing (via FaceTime), copies of this report, LIC 811 Confidential Names List and the Licensee Rights (LIC9058 01/16) were provided to the Program Director at the conclusion of the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2022 02:37 PM - It Cannot Be Edited

Created By: Vicky Williamson On 10/13/2022 at 01:25 PM

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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACKSON HOUSE EL CENTRO	FACILITY NUMBER: 134604232
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/28/2022 Section Cited CCR 81075(b)(5)(B)	1 2 3 4 5 6 7	Health- Related Services b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. 5)If the client's physician has stated in writing... (B) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Director of Nursing (DON) will complete training with an outside source to include all nurses and mental health technicians. DON will submit will submit proof of completion of training to LPA Williamson by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, S1, S2 and S3 administered the incorrect medication to 1 out of 14 clients in care, which poses an immediate Health risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Simon Jacob

LICENSING EVALUATOR NAME:

Vicky Williamson

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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