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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005943
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:12:59 PM

Document Has Been Signed on 03/06/2024 03:12 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MANDEL HOUSEFACILITY NUMBER:
306005943
ADMINISTRATOR:YVETTE DORANFACILITY TYPE:
735
ADDRESS:2220 CONCORD STREETTELEPHONE:
(818) 782-2211
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Jason Ferraris - AdministratorTIME COMPLETED:
03:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting a Case Management Inspection to follow up on an incident report. LPA was greeted and granted entry by DSP Caitlyn Elliot. The Administrator Jason Ferraris arrived approximately 30 minutes after LPA's arrival.

LPA re-stated the purpose of the inspection. LPA is following up on an Incident Report received by Community Care Licensing (CCL) on 2/15/24. The incident was a medication error. The client (C1) was administered two 15mg Abilify pills in the morning. C1's Abilify prescription indicates that C1 take one pill in the morning and one pill in the evening. Administrator received instructions to monitor the client from the prescribing physician.

LPA collected copies of the following: 1. LIC 9020 - Registrar of Facility Clients, 2. C1's Admission Agreement, 3. The February 2024 Centrally Stored Medication and Destruction Record for C1, 4.Communication Log (which staff use to notate observations about clients during their shifts) from 2/15/24 to 2/29/24.

Based on record review, LPA noted that, in the 15 days following the medication error, facility staff only documented observational notes for C1 on the Facility Communication Log on 8 days compared the rest of the clients (each of whom had documented notes on 13 out of the 15 days).

Based on these records, LPA determined the facility did not thoroughly document observations regarding C1 following the medication error. Because of the lack of notes taken in the log, it cannot be verified if the facility staff monitored the client closely enough following the medication error. A deficiency is being issued.

Based on today inspection, one deficiency is being issued. An exit interview was conducted with the Administrator and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 03/06/2024 03:12 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 03/06/2024 at 02:53 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: MANDEL HOUSE
FACILITY NUMBER: 306005943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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AD stated all facility staff will undergo medication training as well as an in-service training regaring taking observational notes. AD stated they will email LPA documentation verifying the date, participants and content of these trainings by the assigned POC due date of 4/5/24.
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Based on interview and record review, the licensee did not ensure C1 received assistance with self-administered medications due to a medication error which resulted in an adverse reaction, which posed an immediate health 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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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