374604207-9-11-2023-08-AS-DNGN-CVKVN5-20230911163435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:35:29 PM

Document Has Been Signed on 09/11/2023 04:35 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 HARMONY		FACILITY NUMBER:	374604207
ADMINISTRATOR:	MANIPON, CHERIFER		FACILITY TYPE:	737
ADDRESS:	2915 DUCK POND LANE		TELEPHONE:	(760) 975-7176
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY: 4		CENSUS: 4	DATE:	09/11/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Cherifer Manipon and Assistant Adminstrator Cynthia Ruiz		TIME COMPLETED:	05:00 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 Administrator Cherifer Manipon and Assistant Administrator Cynthia Ruiz.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 08/07/2023. According to the SIR, during the evening of 08-02-2023, an error by Staff #1 (S1) led to Client #1 (C1) receiving a double/extra dose of one of their prescribed medications. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The overdose did not result in any adverse health consequence for C1.

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

Per their latest LIC602 Physician’s Report, C1 had an “autism spectrum” diagnosis and their doctor determined that C1 required staff assistance with storing and taking their prescribed medications. Due to their baseline intellectual disability, C1 was not able to participate as a reliable historian regarding the incident.

Records and staff interviews showed: S1 quickly recognized their medication error, which was timely reported to C1’s prescribing physician and the San Diego Regional Center (SDRC). Facility staff continued to observe C1, per physician instruction, and C1 did not develop adverse health symptoms. Following the incident, Licensee temporarily removed S1 from medication pass duties until they could be retrained by a Registered Nurse. S1 underwent retraining, to include skills validation, before they were reinstated in medication pass duties.

[CONTINUED ON LIC 812-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: 09/11/2023

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[CONTINUED FROM LIC 812]

A preponderance of evidence exists to show that during the incident in question, Licensee’s staff (S1) did not give medication to C1 as it was prescribed. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D).

Since the deficiency is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Ruiz, to whom a copy of this report, the LIC 809-D, the LIC421-FC, 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: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2023 04:35 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/11/2023 at 04:21 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: 09/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/11/2023 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Based on records and interview: On 08/07/2023, Licensee retrained S1 on accurate medication pass procedures before reinstating them in medication pass duties. Licensee agreed to update its internal medication administration policy/training document(s) to reflect this change: Beyond just comparing the medications themselves to the EMAR, staff are also required to compare the blister pack numbers/dates (where applicable) to the EMAR. Licensee agreed to then retrain its direct care staff team at large on the updated policy. Licensee agreed to E-mail LPA a copy of the updated policy page(s) (i.e., excerpts) and training sign-in sheet, by the POC due date.
	8 9 10 11 12 13 14	Based on records and interview, licensee’s staff (S1) 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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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