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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600429
Report Date: 07/23/2024
Date Signed: 07/24/2024 07:47:57 AM

Document Has Been Signed on 07/24/2024 07:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HELEN WRIGHT, A.R.F.FACILITY NUMBER:
374600429
ADMINISTRATOR/
DIRECTOR:		HELEN WRIGHTFACILITY TYPE:
735
ADDRESS:1418 SOUTH GRADE ROADTELEPHONE:
(619) 445-6667
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Licensee's Helen & Kenneth WrightTIME VISIT/
INSPECTION COMPLETED:
09:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee’s Helen & Kenneth Wright.

Today's visit was in response to a licensee self-reported medication error. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 6/21/24. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 5/16/24 pharmacy did not send client’s (C1) medication. Staff called pharmacy and was told that pharmacy was out of refills. Refills were received on 5/21/24 and staff administered medication to C1 on 5/22/24.

During today’s visit, LPA reviewed records and toured facility. LPA interviewed staff regarding the incident. Staff reported that that the day medications were delivered it was discovered one of C1 medications was missing. Staff immediately contacted pharmacy and was told that they required a renewal from the physician and were working on contacting the physician. There was a delay in the physician responding to the pharmacy’s inquiry which resulted in C1 going without the medication. Facility agreed that moving forward they will contact the pharmacy when a client is down to five days of medication and request to provide an interim supply of medication if there is a delay in reaching the physician.

One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee’s.

An exit interview was conducted with Licensee, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/24/2024 07:47 AM - It Cannot Be Edited


Created By: Alyssa Ramirez On 07/23/2024 at 10:10 AM
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: HELEN WRIGHT, A.R.F.
FACILITY NUMBER: 374600429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist resident with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Licensee agreed to retrain staff on medication administration and implement facility policy to: contact the facility’s contracted pharmacy for refills whenever a client is down to 5 days of medication. Licensee agreed to send a copy of training certificate to LPA by the POC due date.

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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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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