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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604318
Report Date: 02/06/2024
Date Signed: 02/06/2024 05:59:01 PM


Document Has Been Signed on 02/06/2024 05:59 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:WESTMONT OF ENCINITASFACILITY NUMBER:
374604318
ADMINISTRATOR:NEWTON, RANDALFACILITY TYPE:
740
ADDRESS:1920 SOUTH EL CAMINO REALTELEPHONE:
(760) 452-6037
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:101CENSUS: 80DATE:
02/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Executive Director Randal NewtonTIME COMPLETED:
06:15 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 Executive Director Randal Newton.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 01/17/2024. According to the LIC624: during the morning of 01/17/2024, an error by staff led to Resident #1 (R1) receiving double (i.e., twice as much) of their prescribed dose for each of eight (8) of their medications. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. The overdoses did not result in any adverse health consequence for R1.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe and well. LPA collected copies of and reviewed pertinent care and personnel records. LPA also interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/05/2022), R1 was able to administer their own prescription medications. However, according to the latest Service Plan (dated 09/23/2023) which Licensee prepared on R1, they required assistance with medication management. Manager interview also confirmed that R1 now had mild memory impairment and was paying Licensee to help them take their medications during the time of the incident.


[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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: WESTMONT OF ENCINITAS
FACILITY NUMBER: 374604318
VISIT DATE: 02/06/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Staff interview and records showed: Around 7:30 AM on 01/17/2024, Staff #1 (S1), who was assigned to the facility’s second floor, gave one dose each of eight (8) prescribed medications to R1, but did not immediately document their administration in the facility’s electronic Medication Administration Record (MAR) software, as Licensee had trained and expected S1 to do. R1 then went to eat breakfast in the facility’s first floor dining room. Around 8:30 AM, R1 approached Staff #2 (S2), who was assigned to the facility’s first floor, to request their medications. S2, not realizing that S1 had already given R1 their morning medications, gave R2 second doses for each of the same eight (8) medications.

S2 subsequently realized an error had occurred and notified a facility nurse/manager, Staff #3 (S3). S3 observed R1 and took their blood pressure and pulse vital signs, which were in normal range. S3 timely contacted R1’s prescribing physician (PCP) for guidance and timely notified R1’s responsible person (RP) of the incident. S3 personally met with S1 and S2 to discuss the incident, then suspended S1 from medication pass duties. S3 performed formal/written coaching with S1 and retrained them (to include a written test), before reinstating R1 in medication pass duties a few days later. Progress notes show facility staff continued to provide increased observation to R1 for 72 hours following the incident, during which R1 continued to be free of any adverse reaction.

A preponderance of evidence exists to show that during the above incidents, a documentation process error by Licensee’s staff (S1) resulted in R1 not receiving medications exactly as they were prescribed by their physician. 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. LPA issued one (1) Technical Violation (TV) regarding reporting requirements. LPA also provided Technical Assistance (TA) regarding medical assessments.

An exit interview was conducted with Newton, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/06/2024 05:59 PM - It Cannot Be Edited

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: WESTMONT OF ENCINITAS
FACILITY NUMBER: 374604318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Staff interview and personnel records showed: Following the incident, Licensee immediately suspended S1 from medication pass duties, performed written/formal coaching with S1, and then tested S1’s knowledge of med pass procedures, before reinstating S1 back in their med pass duties. Licensee agreed to retrain its larger medication staff team on the importance of immediate recording of medications given in the electronic MAR system, and the potential consequences of not doing so timely. Licensee agreed to submit the training-sign in sheet to LPA, by the POC due date.
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Based on records and interviews, Licensee did not assist 1 of 80 residents (R1) with self-administered medications as needed/prescribed, 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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