Facility Evaluation Report

On 04/02/2026 at 02:15 PM Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a Case Management. LPA met with Administrator, Amelia Alfonso and explained the purpose of the visit.

While LPA P. Manalo conducted a complaint investigation (15-AS-20260130142832), LPA was informed from W1 that there are staff members that are dispensing medications that are not trained.

During the visit, LPA reviewed the staff schedule and 10 of 10 staff members listed as Direct Support Professionals (DSP) DSP all have DSP certification. Interview with 5 of 5 staff members all disclosed that medications should be dispensed and administered by DSP staff. 1 of 5 staff member stated that there if S3 is not available to give medication to the clients, S3 will ask the other staff members to administer it for S3. However, 3 of 5 denied that S3 would ask other staff members to administer the medication on S3's behalf. In addition, 2 of 5 staff members interviewed revealed that there are times when the medication will be pre-poured into a separate cup so that clients can take it later on that day. S1 stated that the medication pre-poured are left in the medicine cabinet, while S4 stated that the clients' medications will be left in a cup inside the kitchen drawer if the client is not back from their outing or wants to take the medication later.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.