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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603587
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:06:19 PM

Document Has Been Signed on 03/13/2023 02:06 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:CHANCELLOR HOMEFACILITY NUMBER:
374603587
ADMINISTRATOR:ASTRID GARCIAFACILITY TYPE:
735
ADDRESS:13904 CHANCELLOR WAYTELEPHONE:
(858) 842-4534
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 4CENSUS: 3DATE:
03/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee Astrid GarciaTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Dang Nguyen and Alyssa Ramirez conducted an unannounced Case Management visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with licensee Astrid Garcia.

Today's visit was in response to two Special Incident Reports (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 02/15/2023, regarding Client #1 (C1) and Client #2 (C2) both not receiving medication as prescribed, involving multiple days during February 2023. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, all clients in care were at an off-site day program. LPAs performed a facility tour, collected records, and interviewed staff.

Per their respective LIC602 Physician’s Reports, C1 and C2 both required staff assistance with taking their prescribed medications. According to staff interview, and corroborated by personnel records and outside investigative records: Staff #1 (S1) did not give C1 and C2 specific prescribed medications over multiple days during February 2023. Neither C1 nor C2 suffered adverse health consequences as a result of these missed doses.

A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Garcia, 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.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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Document Has Been Signed on 03/13/2023 02:06 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/13/2023 at 01:23 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: CHANCELLOR HOME
FACILITY NUMBER: 374603587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2023
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 personnel records and staff interviews: a) On 02-15-2023, licensee performed written corrective coaching with S1 regarding the medication errors, and b) On 03-07-2023, licensee retrained their direct care staff on medication pass procedures and the Seven Rights of medication administration. These actions resolve the deficiency.
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Based on records and interview, the licensee did not ensure that 2 of 3 clients (C1 and C2) were 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: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
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