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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 02/20/2024
Date Signed: 02/20/2024 01:03:54 PM

Document Has Been Signed on 02/20/2024 01:03 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:
02/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Program Director Cruz MoraTIME COMPLETED:
12:00 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 Assistant Program Director Cruz Mora.

Today's visit was in response to an incident report, which licensee self-submitted to the CCLD San Diego Regional Office on 12/11/2023. According to the report: During the evening of 11/26/2023, an error by staff led to Client #1 (C1) receiving only half of the prescribed dose for one (1) of their medicines. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

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

Per their latest LIC602 Physician’s Report (dated 07/21/2023), C1 was diagnosed with Autism Spectrum Disorder and required staff assistance with taking their prescribed medications.

Records and interviews showed: For one of their medicines, C1 was prescribed two (2) 500 mg tablets per day. During the 11/26/2023 incident, an error by Staff #1 (S1) led to C1 receiving only one (1) of these tablets, instead of two (2). C1 thus received only half their prescribed daily dose. This under-dose did not result in any adverse health consequence for C1.


[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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: 02/20/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Licensee identified the error during a routine audit on 11/27/2023, and timely notified San Diego Regional Center (SDRC) and C1’s prescribing physician (PCP); the PCP did not instruct any special follow up action. Licensee temporarily removed S1 from medication pass duties and had S1 undergo two hours of retraining, before reinstating them in such tasks. S1’s retraining was supervised by a licensed nurse and involved hands-on practice and skills validation. Licensee also implemented two (2) new internal procedures based on lessons learned from the incident.

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, 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 Mora, 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: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2024 05:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/20/2024 04:42 PM


Created By: Dang Nguyen On 02/20/2024 at 12:00 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LIBERTY HARMONY
FACILITY NUMBER: 374604207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
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 manager interview: On 11/30/2023, Licensee retrained S1 on accurate medication pass procedures before reinstating them in medication pass duties. Licensee also implemented two (2) new internal procedures based on lessons learned from the incident. These actions resolve the deficiency.
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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.
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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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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