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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 02/20/2024
Date Signed: 02/20/2024 04:38:23 PM

Document Has Been Signed on 02/20/2024 04:38 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 TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:CYNTHIA RUIZFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 625-5106
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
02/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Lead BSP Trevor Sparkman and Assistant Program Director Cruz MoraTIME 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 Lead BSP Trevor Sparkman and Assistant Program Director Cruz Mora.

Today's visit was in response to a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 02/19/2024. According to the SIR, during the morning of 02/16/2024, an error by staff led to Client #1 (C1) not receiving one (1) dose of one (1) of their prescribed medicines. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The missed dose 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, verifying that they were safe. LPA collected copies of and reviewed pertinent records. LPA also interviewed relevant staff.

Per their latest LIC602 Physician’s Report (dated 10/02/2023), C1 was diagnosed with Mild Intellectual Disability and Autistic Disorder (among other diagnoses) and their doctor determined that C1 required staff assistance with taking their prescribed medications.

Based on LPA observation: The medication involved in the above incident was a small round pill to be given once per day. The pills were stored inside a “blister pack,” which is an approved, labeled, and numbered card dispensed direct from the pharmacy. Within the blister pack card, each individual pill sits inside its own plastic bubble, and each bubble is backed with a foil lining. When staff push/depress the bubble with their finger(s), the foil lining is meant to break, allowing the pill to fully drop/come out of the card.

[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 TRANQUILITY
FACILITY NUMBER: 374604208
VISIT DATE: 02/20/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Staff interviews, corroborated by records, showed: During the AM shift on 02/16/2024, Staff #1 (S1) was assigned to give C1 their prescribed morning medications, and Staff #2 (S2) was assigned to witness and verify that S1 gave them accurately. For the medication in question, the bubble of the blister pack was pressed, but the pill did not fully dislodge and come out. The pill remained trapped in the blister pack, rather than being given to C1, as was prescribed. PM Shift Staff #3 (S3) and NOC/Overnight Shift Staff #4 (S4) were both responsible for inspecting C1’s blister packs to ensure that their AM shift teammates correctly gave C1 their AM medications.

Licensee discovered the medication error during the 02/18/2024 AM shift, when Staff #5 brought it to the attention of facility management. Upon learning of the medication error, License timely reported it to C1’s San Diego Regional Center (SDRC) coordinator and C1’s prescribing physician (PCP). The PCP did not instruct any special follow up action. The missed dose did not result in any adverse health consequence for C1.

A preponderance of evidence exists to show that during the above incident, 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 04:38 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/20/2024 at 04:05 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2024
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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Licensee agreed to retrain its line staff at large (i.e., including, but not limited to, S1 through S4) on the importance of performing both a visual and a tactile check of the blister pack bubbles to ensure that pills fully drop out after the bubbles are popped (and during subsequent internal audits). Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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Based on records and interview, licensee’s staff 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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