374604208-4-20-2023-08-AS-DNGN-CR3RZR-20230420132824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 04/20/2023
Date Signed: 04/20/2023 01:28:31 PM

Document Has Been Signed on 04/20/2023 01:28 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 TRANQUILITY		FACILITY NUMBER:	374604208
ADMINISTRATOR:	SMITH, DAVID		FACILITY TYPE:	737
ADDRESS:	1404 ASH STREET		TELEPHONE:	(760) 654-6277
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY: 4		CENSUS: 4	DATE:	04/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Registered Nurse Jennifer Peters, Quality Assuance Manager Morgan Davis, and Assistant Program Manager Mitch Blackwood		TIME COMPLETED:	01:30 PM

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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 Registered Nurse Jennifer Peters. LPA also met with Quality Assurance Manager Morgan Davis and Assistant Program Manager Mitch Blackwood, who arrived later during the visit.

Today's visit was in response to three (3) Special Incident Reports (SIRs) regarding medication errors, all involving Client #1 (C1), which licensee self-submitted to the CCLD San Diego Regional Office. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] According to the first and second SIRs (both received 02-22-2023): between 02/20/2023 and 02/21/2023, staff did not give to C1 (i.e., they missed) three (3) of four (4) doses of their prescribed eye drop medication. These errors were discovered via an internal self-audit. According to the third SIR (received 03/20/2023): Staff did not give to C1 (i.e., they missed) one (1) dose of their prescribed nebulizer medication on 03/17/2023. This error was also discovered via an internal self-audit. Per the SIRs: the above missed doses did not result in any adverse health consequence for C1.

During today’s visit, LPA performed a brief facility tour and attempted a welfare check on clients, but all four (4) clients (including C1) were off-site, either at doctor’s appointments or on recreational outings with staff. LPA interviewed pertinent staff and reviewed relevant records.

Per their latest LIC602 Physician’s Report, C1 was diagnosed with “mild intellectual disability” and required staff assistance with taking their prescribed medications. Manager interviews confirmed that C1 indeed needed staff help with taking their medications, and C1 was indeed unharmed/uninjured from these incidents.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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 TRANQUILITY	FACILITY NUMBER: 374604208
	VISIT DATE: 04/20/2023

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[CONTINUED FROM LIC 809]

Licensee’s own internal investigation revealed: Staff #1 (S1) was involved in the 02-20-2023 to 02-21-2023 incident, and Staff #2 (S2) was involved in the 03-17-2023 incident. Interviews showed that upon the discovery of the medication errors, licensee immediately withdrew S1 and S2 from medication pass tasks. Licensee’s nurse manager retrained both on medication pass procedures, before allowing them to resume medication pass tasks.

Based on records and interviews, 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 and Blackwood, 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/20/2023 01:28 PM - It Cannot Be Edited

Created By: Dang Nguyen On 04/20/2023 at 01:04 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 TRANQUILITY	FACILITY NUMBER: 374604208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2023 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	Interviews showed that upon the discovery of the medication errors via internal audit, licensee immediately withdrew S1 and S2 from medication pass tasks. Licensee’s nurse manager retrained both on medication pass procedures, before allowing them to resume medication pass tasks. Licensee agreed to E-mail LPA copies of paperwork evidencing the retrainings for S1 and S2, by the POC due date.
	8 9 10 11 12 13 14	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.	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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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