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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294182
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:29:50 PM

Document Has Been Signed on 11/29/2022 01:29 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DRAKE HOUSEFACILITY NUMBER:
275294182
ADMINISTRATOR:JULIE HUYNHFACILITY TYPE:
740
ADDRESS:399 DRAKE AVENUETELEPHONE:
(831) 643-9069
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 55CENSUS: 50DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jenny LambarteTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit regarding a self reported medication error that was received in Fresno Regional Office (RO) on 11/23/22. LPA met with Jenny Lambarte, Residential Services Manager during today's visit.

Per report received in Fresno RO on 11/22/22, R1 received the incorrect dosage of medication. R1's physician orders were changed on 11/18/22, R1’s current medication dosage was increased. Facility received new medication delivery on 11/21/22 however failed to discontinue R1’s old prescription resulting in R1 receiving both dosages.

R1’s physician was contacted and no additional medical treatment required. R1's conservator also notified by e-mail.

LPA informed that staff will receive mandatory medication training on 11/30/22. LPA received copies of Physician report, physician orders, MARS, and e-mail to responsible party,

Deficiency cited on the attached 809D

Exit interview conducted. Appeal rights given.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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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Document Has Been Signed on 11/29/2022 01:29 PM - It Cannot Be Edited


Created By: Melinda Medina On 11/29/2022 at 01:03 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DRAKE HOUSE
FACILITY NUMBER: 275294182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions. **This was not met as evidenced by, on 11/23/22 facility self reported to
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Facility will conduct Medication Training for Med Techs on 11/30/22. POC, sign in sheets and agenda will be submitted to Fresno RO office no later than POC due date.
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Fresno RO medication error for R1 which occurred on 11/22/22.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
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