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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of several incident reports (SIR) for client (C1). LPA met with House Lead, Crystal Paulus and DSP's, Jeanne Gold and Stacey Takara. LPA observed staff Jeanne to be playing a game at the table with client (C2). The new Administrator, Kizzy Thorn, had just left the facility prior to LPA's arrival. LPA discussed SIR's for (C1) from 10/23/23 and 10/29/23 where (C1) refused bedtime medications.
The House Lead assisted LPA in reviewing Medication Administration Record (MAR) for September 2023 showing missed bedtime medications (4 dosages) for (C1) from 9/8/23- 9/27/23. LPA discussed the reason for the missed medications with the House Lead, DSP and facility nurse, Alex. All interviews revealed that (2) psychiatric medications were not filled timely and (C1) missed the (4) dosages. As a result, (C1) had behavioral concerns during this time period. The nurse stated to LPA that the new psychiatric physician wouldn't refill any prescriptions until (C1) was seen in person, which (C1) was refusing to do on multiple times. DSP stated that staff finally was able to have (C1) go to his primary care physician who asked to confirm which medications needed a refill. The earliest (C1) could be seen was on 10/20/23 with the psychiatric doctor.
DSP and House Lead stated there is not a refill number listed on the medication bubble packs and they do not monitor the refill status. LPA observed the bubble pack for (C1) and did not see a reference to any refills. LPA observed on pharmacy paperwork, dated 6/9/23, that (2) refills were available for the (2) psychiatric medications that ran out on 9/8/23. The Administrator at the time sent a SIR to the Department on 9/9/23 to report that (8) medications prescribed from (C1's) primary care physician were missed on 9/9/23 due to wildfire at that time; however, a SIR was not sent for the (2) medications ((4) dosages) missed from 9/8/23- 9/27/23.
Per California Code of Regulation Title 22, Division 6, Chapter 8, the following (2) deficiencies are issued on the 809D page.
Exit interview. Copy of report and appeal rights emailed due to technical difficulties. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/09/2023
Section Cited
CCR
80075(b)(5)(B)
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7 | 80075 Health Related Services
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: | 1
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7 | Licensee/Administrator/House Lead agree to conduct staff training to better the monitor refills and to order a refill(s) two to four weeks prior to the medication running out.
House Lead agrees to discuss with Kizzy, new Admin, and send LPA a training agenda by 11/9/23.
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14 | Based on documentation reviewed and interviews conducted, the Licensee did not ensure that (C1) received (4) of (4) scheduled medication dosages for bedtime from 9/8/23- 9/27/23, which posed an immediate health and safety risk to clients in care. | 8
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Type B
11/22/2023
Section Cited
CCR80061(b)(1)(E)
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7 | 80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
(1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
1. For community care facilities that serve children, a pregnancy or termination of a pregnancy does not, in and of itself, constitute an unusual incident unless it meets the criteria specified for mandated reporting in Penal Code section 11166 (a).
This requirement is not met as evidenced by: | 1
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7 | Licensee/Administrator/House Lead agree to read Regulation 80061 and submit a signed statement to CCLD that it is understood.
Documentation due by 11/22/23. |
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14 | Based on documentation review, the Licensee did not ensure that an incident report for the missed medications for (C1) from 9/8/23- 9/27/23 was submitted to the Department, which posed a potential health and safety risk to clients in care. | 8
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