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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202542
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:33:00 PM

Document Has Been Signed on 11/28/2023 12:33 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SUCCESS IN RECOVERYFACILITY NUMBER:
547202542
ADMINISTRATOR:SHAWNAA SUPNETFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Shawnna SupnetTIME COMPLETED:
12:30 PM
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On November 28, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery Short-Term Residential Therapeutic Program in Visalia, CA, to conduct a Case Management and met with Administrator, Shawnna Supnet. The purpose of the inspection is to discuss an incident report that was submitted to the department on 11/21/2023 regarding client 1 (C1) being administered incorrect medication by Staff 1 (S1). (See attached LIC 811)

On November 20, 2023, at 8:24 pm, C1 was given incorrect medication, C1 was given C1’s morning medication by S1 instead of the evening medication, the mistake was realized after C1 swallowed the medication. C1 stated that it would interfere with sleep pattern. S1 called and reported this incident to the Administrator (ADM). ADM made sure that all staff were checking on C1 regularly throughout the night.

LPA Galvan reviewed files and conducted interviews. LPA discussed with ADM the concerns of S1 administering incorrect medication, the importance of all staff verifying & confirming the correct medication is being administered and maintaining medication quality assurance.

Based on interviews and record review, the Agency is being cited for the Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section 80075 Health Related Services.

An exit interview was conducted to discuss this report and appeal rights. A copy of this report, appeal rights, and LIC 811 were provided to Shawnna Supnet at the conclusion of the inspection.

SUPERVISORS NAME: Lourey Bartolome
LICENSING EVALUATOR NAME: Vanessa Galvan
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 11/28/2023 12:33 PM - It Cannot Be Edited


Created By: Vanessa Galvan On 11/28/2023 at 11:56 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUCCESS IN RECOVERY
FACILITY NUMBER: 547202542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
HSC
80075(b)

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80075(b) Health Related Services.
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by
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The Adminstrator stated that they will complete a retraining with staff regarding administering medications. Adminstrator will contact staff by 11/28/2023 to schedule training. Adminstrator will provided proof of retraining via email.
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Based on record review and interviews, a staff did not properly assist a client by giving the client the incorrect medication. Which poses an immediate Health, Safety or Personal Rights risk to the 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:Lourey Bartolome
LICENSING EVALUATOR NAME:Vanessa Galvan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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