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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:49:39 PM

Document Has Been Signed on 04/05/2023 03:49 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:VICKI PACHECOFACILITY TYPE:
772
ADDRESS:115 MADRONE AVENUETELEPHONE:
(669) 888-3182
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 15CENSUS: 8DATE:
04/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:JENNIFER NGUYENTIME COMPLETED:
03:55 PM
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Licensing Program Analysts (LPA) Christine Dolores and Manuel Monter arrived unannounced to conduct a case management - incident visit. LPAs met with Program Supervisor, Angelica Suud and Administrator, Jennifer Nguyen.

On 02/01/23, 02/02/23, 02/11/23, and 03/11/23 the Department received incident reports regarding medication errors at the facility. From 02/01/23 - 02/02/23, a client's (C1) was given wrong medication two days in a row. On 02/11/23, client (C1) was given double dose of medication at once. On 03/11/23, client (C2) was not given a medication during a medication pass. Client's medical professionals were notified of the incidents and monitored for any signs and symptoms.

After the incidents in February 2023, the facility had provided an in-service training to staff on the topic of MedRoom procedures. An in-service training was provided twice in the month of February 2023 to include one in-depth training on MedRoom procedures. During visit, LPAs reviewed and obtained the in-service training documentation's which included the date, length of course, participants signature, training topics, and instructor. LPAs also reviewed the facility's MedRoom procedures with staff (S1) who is a licensed professional and responsible for providing medication training. Staff (S2) was also present during the demonstration. LPAs did not observe concerns regarding the facility's MedRoom procedures.

During visit, LPAs toured the facility to include the backyard, resident rooms, and common areas. LPA Dolores interviewed 3 staff members (S1 - S3) regarding the medication errors. Based on interview, S1 - S2 stated medication errors could be due attributed to staff "rushing" through the process. The following documents were reviewed and obtained to include 3 staffs (S4 - S6) annual training records and facility correspondences.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Jennifer Nguyen and a copy of the report and appeals rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/05/2023 03:49 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/05/2023 at 03:14 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: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2023
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 will submit their plan of action in writing to LPA via email by POC due date.
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Based on obseveration, interview, and record review the facility reported multiple medication errors to the Department from multiple staff members 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: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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