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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 04/17/2023
Date Signed: 04/17/2023 05:15:13 PM

Document Has Been Signed on 04/17/2023 05:15 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:LIBERTY HARMONYFACILITY NUMBER:
374604207
ADMINISTRATOR:MANIPON, CHERIFERFACILITY TYPE:
737
ADDRESS:2915 DUCK POND LANETELEPHONE:
(760) 975-7176
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
04/17/2023
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:DSP Justin Griggs and Quality Assurance Manager Morgan DavisTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Justin Griggs. LPA also met with Quality Assurance Manager Morgan Davis, who arrived later during the visit.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 01-17-2023. According to the SIR, on the evening of 01-13-2023, an error by Staff #1 (S1) led to Client #1 (C1) not receiving one (1) of their medicines as prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. Licensee wrote they temporarily removed S1 from medication duties until they could be retrained, and that the missed dose did not cause any adverse health consequence for C1.

During today’s visit, LPA performed a facility tour and welfare check on the clients who were present, verifying that C1 was indeed unharmed/uninjured. LPA also interviewed relevant staff and collected pertinent records.

Per their latest LIC602 Physician’s Report, C1's was diagnosed with "severe intellectual disability" and they required staff assistance with taking their prescribed medications.

Due to their baseline limited verbal skills, C1 was not able to participate as a reliable interviewee.

According to staff interview and corroborated by audit records from San Diego Regional Center (SDRC): during the above incident, S1 gave C1 only half of their prescribed dose for one (1) medicine. Licensee arranged for their nurse manager to retrain S1 following the incident.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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: LIBERTY HARMONY
FACILITY NUMBER: 374604207
VISIT DATE: 04/17/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

One (1) deficiency was 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 Davis, 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: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2023 05:15 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2023 at 04:59 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: LIBERTY HARMONY
FACILITY NUMBER: 374604207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
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 licensee, after discovering the medication error, they temporarily suspended and then retrained S1 on medication pass procedures using a skills checklist. Licensee agreed to send LPA a copy of documentation evidencing S1's corrective training, by the POC due date.
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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: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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