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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603049
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:58:10 PM

Document Has Been Signed on 07/06/2023 03:58 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:UTOPIA HOMEFACILITY NUMBER:
374603049
ADMINISTRATOR:HAVERLY, HANNAHFACILITY TYPE:
735
ADDRESS:11285 PEGASUS AVETELEPHONE:
(858) 564-8190
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 4DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Irence "Brigitte" SimmonsTIME COMPLETED:
04:10 PM
NARRATIVE
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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 Administrator Irence "Brigitte" Simmons. LPA also spoke to Licensee Hannah Haverly via phone during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 04/10/2023. According to the LIC624, during the afternoon of 04/06/2023, errors by Staff #1 (S1) led to Client #1 (C1) receiving doses of multiple medications which were not prescribed to them. [These medications were instead prescribed to Client #2 (C2)]. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. After these medication errors occured, C1 experienced drowsiness and was evaluated at a local hospital, but was not admitted. C1 was discharged back to the facility later the same night, having returned to their baseline condition.

During today’s visit, LPA performed a brief facility tour and welfare check on C1, verifying that they were safe and alert. LPA also reviewed pertinent facility and hospital records, and interviewed relevant staff.

Per their latest LIC602 Physician’s Report (dated 06/14/2022), C1 was diagnosed with Mild Intellectual Disability and seizures (among other diagnoses) and required staff assistance with taking their prescribed medications. C1 was not able to participate as a reliable historian/interviewee about the incident.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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: UTOPIA HOME
FACILITY NUMBER: 374603049
VISIT DATE: 07/06/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

According to records and staff interview: Upon discovery of the medication errors, S1 timely notified facility management, who timely phoned C1’s physician’s office, C1’s responsible person, and C1’s case management agency (San Diego Regional Center). Licensee immediately removed S1 from medication pass duties, retraining them (to include skills validation), before reinstating S1 in those tasks. On 04/10/2023, Licensee also retrained its direct care team at large on accurate medication pass procedures, and this training included S1 as an attendee. The medication errors which affected C1 on the afternoon 04/06/2023 did not prevent C2 from receiving their respective prescribed medications on that date.

A preponderance of evidence exists to show that on at least one day, Licensee did not accurately assist C1 with self-administration of medications. C1 experienced acute drowsiness which resolved later the same day. C1 did not suffer any lasting illness or injury from this incident. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D).

An exit interview was conducted with Simmons and Haverly, to whom a copy of this report, the LIC 809-D, 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2023 03:58 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/06/2023 at 03:26 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: UTOPIA HOME
FACILITY NUMBER: 374603049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
80075(b)

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80075 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:
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Per training records and management interview: Licensee privately counseled and retrained S1 the same day of the incident. Then on 04/10/2023, Licensee retrained its larger direct care staff team on accurate medication pass procedures. During late April 2023, S1 subsequently resigned from facility employment. No further action is required to resolve the deficiency.
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Based on records and interview, the licensee did not ensure that 1 of 4 clients (C1) was assisted as needed with self-administration of prescription medications, which posed a potential 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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