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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800022
Report Date: 12/19/2023
Date Signed: 12/20/2023 01:22:10 PM

Document Has Been Signed on 12/20/2023 01:22 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA PACIFICAFACILITY NUMBER:
565800022
ADMINISTRATOR:THERESA PLANTEFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 40CENSUS: 22DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Assistant Director of Campus Services (ADCS)TIME COMPLETED:
01:14 PM
NARRATIVE
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On December 20, 2023 at 12:40pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conduct a case management deficiency. LPA was met by Assistant Director of Campus Services (ADCS) who granted access to the facility.
A medication incident report SIR #22781, dated 12/7/23 was reported to Community Care Licensing (CCL) and did not contain information on type of medication missed due to medication not being "packed." LPA requested licensee to provide further information and to re-submit SIR. On 12/11/23, licensee sent the revised SIR to the regional office. During the course of the deficiency investigation it was discovered that licensee did not ensure psychotropic medication for youth (C1) were taken or administered as prescribed, "due to being forgotten about until after window to pass medication."
LPA Wilson and Licensee discussed the possible mitigating factors which led to the missed medication dosage. Licensee stated the nurse did prepare the medications to be administered, however, were not administered to client (C1). Further, staff signed off on the medication form which had a discrepancy. The pre-shift form was not completed that day.
A (1) deficiency Type A has been determined at this time.

The following deficiency has been cited. (See LIC 809D)



An exit interview was conducted and Plans of Correction was developed and reviewed with the licensee. A copy of this report and appeals rights were discussed and left with licensee. (ADCS) whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Kevin C Sauk
LICENSING EVALUATOR NAME: Christine Wilson
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 12/20/2023 01:22 PM - It Cannot Be Edited


Created By: Christine Wilson On 12/19/2023 at 01:07 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA PACIFICA
FACILITY NUMBER: 565800022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services
(b) Clients shall be assisted as needed...(5) If the client's physician has stated in writing that the client…(B)...the medication is given according to physician's directions.This requirement is not met as evidenced by:
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Licensee will update Plan of Operation to include a copy of the Pre-Shift Form and medication protocols.
Licensee will ensure staff are trained on Psychopharmacology for Children and Aolescents, and send proof of completed training hours to LPA by due date.
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Based on incident report 12/11/23, LPA records review and interview conducted the licensee did not ensure client received psychotropic medication according to physician's direction which poses an immediate danger to the 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:Kevin C Sauk
LICENSING EVALUATOR NAME:Christine Wilson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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