374604207-10-5-2023-08-AS-DNGN-CWBP6H-20231005110223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:02:45 AM

Document Has Been Signed on 10/05/2023 11:02 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
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:	10/05/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Quality Assurance Manager Morgan Davis		TIME COMPLETED:	11:10 AM

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 Quality Assurance Manager Morgan Davis.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 09/28/2023. According to the SIR, during the evening of 09/25/2023, an error by Staff #1 (S1) led to Client #1 (C1) receiving only the half prescribed dose for one (1) of their medications. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

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.

Care records and staff interviews showed: Licensee identified the medication error during a self-audit the next day on 09/26/2023. C1 did not experience any observable adverse symptoms from the underdose. C1’s physician and San Diego Regional Center were timely notified. 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 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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: 10/05/2023

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[CONTINUED FROM LIC 809]

A preponderance of evidence exists to show that during the incident in question, Licensee’s staff (S1) did not give a 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 Davis, 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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 11:02 AM - It Cannot Be Edited

Created By: Dang Nguyen On 10/05/2023 at 10:50 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: LIBERTY HARMONY	FACILITY NUMBER: 374604207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2023 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	On 09/28/2023, Licensee retrained S1 on accurate medication pass procedures before reinstating them in medication pass duties. This action resolves the deficiency.
	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 correctly 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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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