370800930-10-23-2023-08-AS-DNGN-CWASPP-20231004140328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370800930
Report Date: 10/04/2023
Date Signed: 10/23/2023 01:58:43 PM

Document Has Been Signed on 10/23/2023 01:58 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:	ST MADELEINE SOPHIES CENTER		FACILITY NUMBER:	370800930
ADMINISTRATOR:	DEBRA EMERSON		FACILITY TYPE:	775
ADDRESS:	2119 E. MADISON AVENUE		TELEPHONE:	(619) 442-5129
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY: 400		CENSUS: 370	DATE:	10/04/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Chief Executive Officer Debra Emerson and Assistant Director of Programming Mark Louis Fisher		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chief Executive Officer Debra Emerson and Assistant Director of Programming Mark Louis Fisher.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/29/2023). According to the SIR: During a daytime community outing on 09/21/2023, errors by Staff #1 (S1) led to Client #1 (C1) not receiving their as-needed (PRN) medications according to how they were prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on C1, finding that they were safe, alert, and participating in an activity. LPA also reviewed pertinent care records and interviewed relevant staff.

According to care records: C1 was diagnosed with Profound Intellectual Disability and Mild Cerebral Palsy (among other diagnoses). Manager and staff interviews unanimously confirmed that C1 required staff assistance with storing and taking their prescribed medications.

Staff interviews and care and personnel records showed: Before taking clients on daytime outings, staff are required to place clients’ routine medications in blue pouches, and then the clients’ PRN medications in red pouches. This color-coding practice is meant to aid the staff in medication administration accuracy. Leading up to the 09/21/2023 outing, Staff #2 (S2) placed C1’s routine and PRN medications alike into a single blue pouch, and then handed this pouch to S1 to take with them. During the outing itself, C1 did not exhibit signs, symptoms, or criteria to justify/warrant receiving their PRN medications. Nonetheless, S1 mistakenly gave C1 doses of two (2) as-needed PRN medication, as if these were routine medications. S1 did not read and verify the labels which were affixed to the medication bottles before giving said medications to C1. CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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: ST MADELEINE SOPHIES CENTER	FACILITY NUMBER: 370800930
	VISIT DATE: 10/04/2023

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[CONTINUED FROM LIC 809] Following the incident, C1 did not suffer any observable adverse health symptoms. Licensee formally disciplined and retrained S1 on accurate medication pass procedures.

A preponderance of evidence exists to show that during the incident, Licensee’s staff (S1) did not give C1 their medications as they were prescribed. The incident did not result in illness or injury to C1.

Also, during records review, LPA observed that although C1 had been a participant of the day program since 2003, Licensee did not possess an LIC602 Physician’s Report or equivalent Medical Assessment for C1, as was required. Manager interviews confirmed no such document was in C1’s care file.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. LPA also issued one (1) Technical Violation regarding Reporting Requirements.

An exit interview was conducted with Emerson and Fisher, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 02:05 PM - It Cannot Be Edited

Created By: Dang Nguyen On 10/04/2023 at 12:45 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: ST MADELEINE SOPHIES CENTER	FACILITY NUMBER: 370800930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/03/2023 Section Cited CCR 82075(b)	1 2 3 4 5 6 7	82075 Health Related Services: “(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Personnel records, corroborated by staff interviews, showed: on 09/22/2023, Licensee formally disciplined S1 regarding the incident. Licensee agreed to retrain the pertinent members of its larger direct care staff team (i.e., those involved in medication administration duties) on accurate medication pass procedures. The training will cover, at minimum: a) Adherence to the color-coded pouch system which Licensee uses, and b) Consistent performance of the Seven Rights of Medication Administration. The training participants will include S1 and S2, among others. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
	8 9 10 11 12 13 14	Based on records and interview, the licensee did not ensure that 1 of 370 clients (C1) was assisted as needed with self-administration of prescription medications as they were prescribed, which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
Type B 11/03/2023 Section Cited CCR82069(a)(1)	1 2 3 4 5 6 7	82069 Client Medical Assessments: “(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client…(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.”	1 2 3 4 5 6 7	Licensee agreed to coordinate with C1’s physician and/or responsible party to obtain a complete and signed LIC602 Physician’s Report (or equivalent Medical Assessment) for C1. Licensee agreed to audit other all other current clients’ care records to ensure each has such a document in their care file. Licensee agreed to retrain its managers and admissions staff on all required client documents at time of enrollment in the day program. Licensee agreed to E-mail a copy of C1’s physician’s report, and the training sign-in sheet to LPA, by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on LPA observation and staff interview, for 1 of 370 clients (C1), licensee did not obtain a written medical assessment of the client, performed by a licensed physician or designee completed within the last year, within 30 calendar days of the client’s enrollment in the day program.	8 9 10 11 12 13 14

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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