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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:04:48 AM

Document Has Been Signed on 10/06/2022 10:04 AM - 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: 3DATE:
10/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Patrick Seawright (Administrator)TIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator Patrick Seawright.

During today's visit LPA is following up on an incident report received at CCL on 9/9/22 involving resident (R1). Per incident report, on 9/8/22 it was discovered by staff that on 9/8/22 staff (S1) administered to resident (R1) an additional dose of Lamotrigine 25mg. S1 should have administered Lamortrigine 100mg one tablet by mouth instead of Lamortrigine 25mg one tablet by mouth in addition to Lamotrigine 100mg one tablet by mouth resulting in R1 received incorrect dosage. 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. S1 was placed on Administrative Leave pending an internal investigation by People's Care in accordance to their policy and procedures.

During today’s visit LPA was provided with the Medication Assessment Record (MAR) for the month of September 2022 for C1 that reflects the said medication error. Per Administrator, S1 was aware of the medication changes but apparently got confused when was the start date after been told to start "next week" and did not make an attempt to contact Administrator for guidance. S1 was officially separated from the facility effective 10/5/22.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Civil penalties are issued today in the amount of $250 per repeated violation within 12 months. Exit interview was conducted with the Administrator and appeal rights were emailed to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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 10/06/2022 10:04 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/06/2022 at 09:31 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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
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 to ensure all residents receive their medication as prescribed by their physician. Administrator terminated staff (S1) effective 10/5/22. Administrator agreed to submit LIC9098 that the staff understand the regulation.
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Based on records review of facility self-incident report dated 9/9/22 and interviews conducted with Administrator, the facility staff (S1) on 9/8/22 incorrectly assisted resident (R1) and given an extra dosage of medication Lamotrigine 25mg which poses an immediate risk to the health and safety of the clients in care.
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***Civil penalties are issued today in the amount of $250 per repeated violation within 12 months.

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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: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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