Incident investigation·April 7, 2025

Licensing Program Analyst (LPA) Brian Balisi  conducted an unannounced Case Management - Incident visit. Upon arrival LPA  met with Cristina Williams and explained the reason for the visit. On 03/25/2025, 03/31/2025 and 04/01/2025 the Department received three (3) separate self reported incident reports for missed medications for Client #1 (C1) and Client #2 (C2). On 03/24/2025, it was discovered C1 was not passed their medication on the morning of 03/23/2025. On 03/30/2025, it was discovered  C2 was not passed their medication on the morning of 03/28/2025. On 04/01/2025, it was discovered  C2 was not passed their AM medication. No side effects or concerns were reported for each instances. Two (2) out of the three (3) staff were retrained. The third staff is in process of re-training at this time. At approx - 01:15 p.m. LPA conducted physical plant, interviewed staff, observed staff passing out medication with new medication administration protocol. LPA also reviewed and obtained copies of pertinent documentation relevant to the investigation. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeals rights discussed and copy of report issued.