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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 07/07/2022
Date Signed: 07/07/2022 12:04:20 PM

Document Has Been Signed on 07/07/2022 12:04 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:PEOPLE'S CARE CHARMIANFACILITY NUMBER:
496803639
ADMINISTRATOR:SEAWRIGHT, PATRICKFACILITY TYPE:
740
ADDRESS:5087 CHARMIAN DRTELEPHONE:
(951) 775-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Patrick Seawright (Licensee)TIME COMPLETED:
12:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee Patrick Seawright. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on an incident report received at CCL on 6/6/22 involving resident (R1). Per incident report, on 6/3/22 at around 5:00pm it was discovered by staff that on 6/2/22 staff (S1) administered to resident (R1) an additional dose of Lamotrigine 25mg. S1 should have administered Lamortrigine 25mg two tablets by mouth instead of three tablets by mouth. Upon the discovery about the incorrect dosage that was provided to resident. R1 was monitored for any adverse reaction or change in condition observed. Responsible parties including their Physician, NBRC and CCL were notified. As a preventive plan, the Administrator will discipline S1 according to facility policy and procedure regarding medication error and S1 will be retrained on the Medication Administration Policy and Procedure then will demonstrate the appropriate skill and knowledge to the Administrator prior to being allowed to administer medications to residents in care.

During today’s visit LPA was provided with facility training records for S1 dated 6/6/22 between 1:00pm to 2:00pm. Training subjects include medication management, medication storage requirements and check, medication 15min check, medication errors and reporting, medication competency test and medication certification practicum checklist to remind staff to follow physician’s directions and assist clients with their medications as prescribed.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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 07/07/2022 12:04 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/07/2022 at 11:40 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care. (c)...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement had not been met as evidence by:
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Administrator/Licensee to ensure all residents receive their medication as prescribed by their physician. Administrator to submit a plan of how they will ensure medication is properly given and logged in the future to be in compliance with regulation by POC due date.
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Based on records review of facility self-incident report dated 6/4/22 and interviews conducted with Administrator, the facility staff (S1) on 6/2/22 incorrectly assisted resident (R1) and given an extra dosage of prescribed medication Lamotrigine 25mg which poses an immediate risk to the health and safety of 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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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