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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800022
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:16:23 PM

Document Has Been Signed on 02/23/2024 02:16 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: 17DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Assistant Director of Residential ServicesTIME COMPLETED:
02:14 PM
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 Licensing Program Analyst (LPA) Christine Wilson conducted an unanounced Case Management Incident inspection at the above listed facility. LPA met with Assistant Director of Residential Services (ADS) and the Facility Clinic Manager (FCM).


This case-management-incident inspection was conducted due to the Department receiving a serious incident report (SIR) reflecting that on 02/11/2024 Youth (C1) missed 3pm Lithium 450 MG due to medication not being packed by the facility nurse (S1). LPA reviewed the relevant documents and confirmed that staff did not provide medication.

LPA Wilson inquired about reason for missed medication. Per the Facility Clinic Manager, there is a new nurse who was right at her 90-day probationary period and she may not have been aware of the need to pack the medication at that time. Normally the 4pm nurse arrives and gives the 3pm medications. There was no nurse on that day so that window was missed. There is a board with the in-between medications listed and she needs to check the board where they shifts are covered and medications written. While she has been on there has been no need for packing. The new nurse was shadowing the regular nurses during her probationary period. LPA and FCM discussed the deficiency and a plan of correction.

A type B (1) deficiency will be cited today. See LIC809D for details.

A copy of this report was discussed with ADS and a copy of this report was left at the facility
SUPERVISORS NAME: Kevin C Sauk
LICENSING EVALUATOR NAME: Christine Wilson
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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Document Has Been Signed on 02/23/2024 02:16 PM - It Cannot Be Edited


Created By: Christine Wilson On 02/23/2024 at 01:32 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: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
80075(5)(B)

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(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 Licensee will provide staff training to all nursing staff regarding the regulatory requirement. ADS will provide proof of training to LPA Wilson by 03/22/24 via email.
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The licensee did not ensure that C1 was administrered the prescribed medications as ordered by their physician. This poses a potential risk to the health, safety and personal rights to children 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: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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