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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:08:21 PM

Document Has Been Signed on 05/24/2022 01:08 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:DAVIS SUMMER HOUSEFACILITY NUMBER:
570317743
ADMINISTRATOR:MAIRA GURROLAFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
(530) 757-1294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: 10DATE:
05/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Julie Kirby, Administrator and Julie Hunter, Co-AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to do a Case management visit regarding a self reported medication error on R1. R1 went on a visit to family, and the facility inadvertently administered the wrong medication upon return. Staff involved in the medication error is no longer employed
at the facility.

Client Advocate 1 was retrained by the Program Manager on Medication Administration. Program Manager and Medication Manager have assumed sole responsibility of reviewing and complying R1'S medication schedule to reduce medication errors while advocate 1 was retrained. There have been no reported medication errors since the re-training and review and compilation schedule has been enacted.

No deficiencies were cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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