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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:09:18 PM

Document Has Been Signed on 08/14/2024 01:09 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/
DIRECTOR:		MATTHEW MIAOFACILITY TYPE:
772
ADDRESS:115 MADRONE AVENUETELEPHONE:
(669) 888-3182
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 15CENSUS: 11DATE:
08/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Angelica SuudTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Program Manager, Angelica Suud.

The purpose of the visit was to address 6 medication errors that occurred on 02/22/24, 02/25/24, 06/14/24, 06/15/24, 06/23/24, 07/31/24. The medications errors were conducted by 5 different staff members. Based on interview, it was stated the facility implemented a new electronic system that was launched in June 2024 to reduce the amount of medication errors. In June 2024, the staff were fully trained on the use of the electronic system. It was stated that the staff members who have participated in the medication errors are talked to after every error. It was stated that all staff on the floor are trained on passing medications, however, 1 staff is scheduled to pass medications per shift. They try to keep the staff who is passing medication consistent throughout the weeks unless there is a call-out. Based on record review, the 5 out of 5 staff members are provided training on medications. The PD states medication training is assigned yearly for all staff.

The facility's plans to continue using the electronic system which has reduced a lot of the medication errors besides the error on 07/31. The facility will also continue group training on medications that is completed at least quarterly. The facility will continue tracking and monitoring staff who are prone to medication errors and take administrative actions, if necessary.

Documents were obtained to include 5 staff members training records, S1's written disciplinary action, and the facility schedule for June - July 2024.

A deficiency was 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. This report was reviewed with Program Manager, Angelica Suud and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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Document Has Been Signed on 08/14/2024 01:09 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/14/2024 at 12:34 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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
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 will provide a written plan on section cited to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure residents were provided proper medications which resulted in medication errors in 6 different occassions which poses 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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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