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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200538
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:13:25 PM

Document Has Been Signed on 01/23/2024 03:13 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:CAMPHILL COMMUNITIES CALIFORNIAFACILITY NUMBER:
445200538
ADMINISTRATOR:JON FLINT & JENNIFER RYDERFACILITY TYPE:
735
ADDRESS:3920 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 6CENSUS: 5DATE:
01/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jon Flint and Jennifer RyderTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s case management – incident visit. LPA met with Associate Director, Jon Flint and Administrator, Jennifer Ryder.

The purpose of the visit was to follow-up on incident reports regarding medication errors. On 11/15/2023 and 01/16/2024, the Department received incident reports for resident (R1) regarding medication errors. During visit, LPA interviewed 2 staff members and observed the medication room.

The first incident reported in November 2023, reported that R1 had missed a weekly vitamin that is to be dispensed every Wednesday. The error was noticed on Saturday. Based on interview, the medication was signed off in the system, however, the medication was not actually dispensed. The medication error was caught by another staff member who immediately informed the ADM. The ADM reached out to R1's physician who provided instructions. R1's conservator was also notified. After the incident, the facility verbally debriefed with the staff and informed the staff on the importance of using their electronic MAR scanner to assist with medication to prevent errors. R1 was reported to be doing well with no changes of condition.

The second incident reported in January 2023, reported that R1 missed a medication. Based on the report and interview, R1 missed the medication because the previous staff did not throw out the empty sleeve of medication, causing it to appear as if there was an adequate stock of R1’s medication.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CAMPHILL COMMUNITIES CALIFORNIA
FACILITY NUMBER: 445200538
VISIT DATE: 01/23/2024
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Staff did not double check the sleeve to ensure the packet was filled with the medication. ADM was notified of the missing medication the following day after it was discovered, and the ADM immediately called an on-call nurse and was able to get a refill of the medication for the next day. R1's physician and conservator was notified. After the incident, ADM verbally debriefed with the staff regarding the error and provided reminders about medication refill and communication. R1 was reported to be doing well with no changes of condition.

During visit, LPA obtained a board of letter regarding the removal of one of the facility's Administrators.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator, Jennifer Ryder and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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