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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:00:34 PM

Document Has Been Signed on 10/25/2023 04:00 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:COMMUNITY SOLUTIONS CRISIS RESIDENTIALFACILITY NUMBER:
435202594
ADMINISTRATOR:JENNIFER NGUYENFACILITY TYPE:
772
ADDRESS:115 MADRONE AVENUETELEPHONE:
(669) 888-3182
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 15CENSUS: 15DATE:
10/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Matthew MiaoTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Program Director, Matthew Miao. The purpose of the visit is to follow-up on an incident report the Department received regarding a medication error at the facility that occurred on 08/05/2023.

On 08/11/2023, the Department received an incident report regarding a medication error for resident (R1) which resulted in R1 missing one medication. Based on interview, R1 missed a medication because staff (S1) became distracted when trying to locate another one of R1's medications. S1 ended up not dispensing one of R1's medications but documented the administration on the medication count sheet. It was later found during the NOC shift's routine medication check, that one of R1's medications was missed. After the incident, the facility met with S1 one-to-one to review what happened and review the medication procedures/process to prevent future mistakes. S1 was also advised to focus on the current medication before moving onto the next. The facility decided to reduce the number of hours S1 works in the medication room. R1 was monitored throughout the day and observed to be within baseline. R1's doctor was informed of the incident. Based on the facility’s compliance history, the Department had conducted a case management visit on 04/05/2023 regarding the facility's frequent medication errors. Upon investigation, it was found the medication error conducted on 08/05/2023 was conducted by the same staff (S1) from previous incidents.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.
A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC. A plan of correction was developed with Program Director, Matthew Miao. This report was reviewed with Program Director, Matthew Miao and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 04:00 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/25/2023 at 03:21 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL
FACILITY NUMBER: 435202594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
81065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs ... This requirement is not met as evidenced by:
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Licensee corrected the deficiency prior to visit by conducting a 1:1 training with S1 and by reducing S1's hours in the medication room. Licensee will submit a letter in writing regarding their action plan on preventing medication errors to LPA Dolores by POC due date.
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Based on interview, record review, and observation the licensee did not ensure resident (R1) was given one of their medication by staff (S1) which poses/posed an immediate health, safety and 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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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