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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005941
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:47:24 PM

Document Has Been Signed on 11/10/2022 01:47 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HORWITZ FAMILY HOUSEFACILITY NUMBER:
306005941
ADMINISTRATOR:MCDONALD, LISAFACILITY TYPE:
735
ADDRESS:1621 PORTOLA AVENUETELEPHONE:
(818) 782-2211
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 6DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Yvette DoranTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management visit. Upon arrival, LPA met with Administrator Yvette Doran. There was 1 client present during the visit. The visit was conducted to discuss an unusual incident report sent to Licensing on 10/25/22.

On 10/20/22 in the morning, Client #1(C1) was found vomiting by Staff #1(S1). C1 informed S1 that she had taken medication the night before(10/19/22) that she does not normally take.

S1 discussed the incident with the evening staff and S2 informed that she had placed the evening medications of C2 into a silver cup and C1 took the medication as she thought they were her medication.. S2 asked C2 if he took the medications. C2 said, "no."

The medications taken were Gabapentin, Lorazepam and Fanapt.

S2 was aware of the error but failed to notify Administrator Yvette Doran and seek medical treatment for C1. S2 monitored C1 throughout the night.

S2 called Administrator Yvette Doran at approximately 7:30 am on 10/20/22 and informed what took place after her peers informed her that she needed to report the incident.

Yvette Doran immediately took C1 to St. Joseph Emergency and notified her family. The Doctor's said C1 will be fine. C1's Metobolic Doctor was also called and he concurred.

See LIC809D for cited deficiency.

An exit interview was conducted and a copy of this report and appeal rights were given to Yvette Doran.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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Document Has Been Signed on 11/10/2022 01:47 PM - It Cannot Be Edited


Created By: Michelle Reed On 11/10/2022 at 01:18 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HORWITZ FAMILY HOUSE
FACILITY NUMBER: 306005941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision-The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Licensee agrees to retrain S2 and all staff on medication administration and reporting requirements and provide proof to Licensing.
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On 10/20/22, S2 failed to supervise residents taking their medication and C1 took C2's medications. C2 did not receive any medications. S2 also did not immediately seek medical treatment for C1.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
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