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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804139
Report Date: 11/12/2024
Date Signed: 11/12/2024 02:47:17 PM

Document Has Been Signed on 11/12/2024 02:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SOLANO HOUSEFACILITY NUMBER:
486804139
ADMINISTRATOR/
DIRECTOR:		HALL, ELIZABETHFACILITY TYPE:
735
ADDRESS:2251,2261,& 2271 S WATNEY WAYTELEPHONE:
(530) 758-2160
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 32CENSUS: 24DATE:
11/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:Jordan Mason (Program Assistant)TIME VISIT/
INSPECTION COMPLETED:
03:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management inspection and met with Jordan Mason (Program Assistant) Shemar Lewis (Associate Director) and Kiarra Cooper (Lead Staff). The visit is due to incident reports regarding medication errors submitted to Community Care Licensing (CCL) on 10/21/24 and 11/5/24 respectively.

Per incident report dated 10/21/24, on 10/8/24 at approximately 1:30am while grave shift was conducting medication count, it was found that client (C1) was distributed 4mg of Lorazepam instead of the prescribed 2mg. Staff notified Program Director, who met with staff that passed the medications to find out what happened. Staff (S1) was passing medications and staff (S2) was verifying. They both reported that C1 was very escalated and kept distracting them when they were trying to give them their medication. Recently, this medication was reduced for C1, who used to have up to 6mg at night. S1 reviewed the process of giving these medications. When Program Director reviewed the instructions found out that it could be an easy mistake as it states to “give 2mg at night” instead of “give one two mg pill at night”. The facility added a highlighted note on the card to ensure it is clear to staff for future reference. The Program Director is working with the pharmacy to transition to different medication cards that have all the medications in one bubble pack to help prevent these mistakes in the future. According to the facility, C1 was on a higher dose prior to this incident, and there was no observed or reported side effects. During today's visit, LPA was informed by facility lead staff the mistake happened because of how the prescription was written because C1 has a prescribed Lorazepam 2mg doctor's order on file and another Lorazepam 2mg order as a PRN. Based on records review provided to LPA by the facility, C1's physician report dated 7/4/24 states prescribed medication as follow: Lorazepam 1mg in the morning (QAM), Lorazepam 2mg at night (QHS) and over-the-counter (PRN) Lorazepam 1mg every 6 hours as needed for anxiety.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SOLANO HOUSE
FACILITY NUMBER: 486804139
VISIT DATE: 11/12/2024
NARRATIVE
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Continued from LIC809...

LPA was provided with written communication between facility staff notifying them about an implemented updated system with client's pharmacies where 70% of clients' medications have been transitioned to get their refills through bubble pack system. The full transition to this system is projected to be completed by the end of the month, this system along with a third step added to current protocol will ensure to prevent medication errors. Regarding identified staff that were responsible for medication management errors were removed from medication duties due to staff not followed current policy and procedures as stated in their training. Also, the facility held a staff medication training on 11/5/24 to address job expectations, copy of signing sheet was provided to LPA. The updated system includes medication audits every night, email regarding any medication refill needed, and assigned lead staff to most shifts to ensure staff are following adequate procedures along with random camera checks during medication dispersal times.

According to second incident report dated 11/5/24, on 11/3/24 at approximate 8pm during grave shift medication count, staff discovered that client (C2) was not passed their 8pm dosage of Olanzapine 5mg. Staff contacted previous shift, who informed them that the medication had been marked as “discontinued” in facility’s QuickMAR. Grave staff verified and found out that the new prescription for C2’s Olanzapine 5mg had not populated into the “Pass” section of QuickMAR was only showing the old prescription as discontinued in the medication pass section of QuickMar. Swing staff followed the MAR. After reviewing the QuickMAR, it was revealed that C2’s new prescription hadn’t populated due to start date was indicated as 11/7/24 and staff had discontinued old prescription of medication too early. As a preventive measure, the facility staff will continue the medication that was marked as discontinued in QuickMAR and will start the new bubble pack as stated on 11/7/24. Staff will be retrained in QuickMAR and leadership will assign a lead staff on swing shift to provide guidance about medication management. During today's visit, LPA obtained copy of updated protocol regarding medication management consisting in assigning a lead person to better communicate regarding verification system in the computer and the physical MARs, a third step was added to current protocol where leads will monitor checks during medication pass. Although, QuickMAR computerized system appeared to be the issue due to system is not populating medications correctly, so the facility will go back to use paper MARs where two staff have to sign and verify current medication on hand along with prescribed dosage and reach out to lead staff for clarifications if needed.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Associate Director, appeal rights were given and a copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 02:47 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/12/2024 at 02:28 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SOLANO HOUSE
FACILITY NUMBER: 486804139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
80075(b)(5)(b)

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80075(b)(5)(b) Health Related Services:
(b) Clients shall be assisted as needed with self-administration of prescription & nonprescription medications. (5)..., providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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The facility submitted proof of staff training for medication mgmt regarding updated protocol to help reduce medication errors. The Associate Director agreed to submit a self-certification form LIC9098 ensuring that clients will be assisted with prescribed medication as prescribed by their physician by POC due date.
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Based on interviews with staff and records review of facility records, facility staff did not ensure that C1 was given medication Lorazepam 4mg instead of lorazepam 2mg. This poses an immediate health, safety and personal rights risk to clients 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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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