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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700981
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:05:24 PM

Document Has Been Signed on 10/01/2024 04:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PHOENIX HOUSE ARF, INCFACILITY NUMBER:
392700981
ADMINISTRATOR/
DIRECTOR:		CAMPBELL, SCOTTFACILITY TYPE:
735
ADDRESS:2428 WARLOW LANETELEPHONE:
(209) 351-4808
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 5CENSUS: 5DATE:
10/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Raye Bolden, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 10/01/24, LPA Campbell arrived to a facility to conduct a case management. LPA Campbell met with Assistant Administrator Raye Bolden. (AAR) And stated the purpose of the visit.

The purpose of the visit is to follow up on a 9/24/24 incident report regarding an incident on 09/23/24. Per the incident report, R1 walked into the medication room and while S1 was turned away, R1 took the medication meant for R2.

LPA Campbell first attempted to verify if S1 was cleared and associated to the facility and if S1 had been trained in medication administration. Upon review, S1 and S2 were cleared but not associated to the facility. AAR was then able to associate S1 and S2 to the facility. LPA Campbell then observed S1 and S2 on the facility roster in Guardian. S1’s file also contained proof of medication training.

LPA Campbell then asked Assistant Administrator Raye to view where and how the alleged medication error occurred. LPA Campbell observed that a half door is used for the medication room. Per the Assistant Administrator, the medication was accessible to clients in care when S1 entered and left the pantry door open. R1 was then able to ingest medication in error.

LPA Campbell will continue case management at a later date. LPA will need more time to research incident.


SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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Created By: Renee Campbell On 10/01/2024 at 03:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PHOENIX HOUSE ARF, INC
FACILITY NUMBER: 392700981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
80075(k)(1)

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80075 (k)(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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The facility will conduct an inservice training for staff regarding medication and submit a sign in sheet as verification by POC date.
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Based on interview, S1 did not keep medication inaccessible to clients when they left the door open to the medication office which poses an immediate health, safety or personal rights 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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
Page: 1 of 1