Facility Evaluation Report
Capacity6
Census3
Date signed12/17/2024 02:24:54 PM
During an complaint investigation (15-AS-20241213161313) on 12/17/24. While doing files reviewed Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander discovered R1 had a fall back in October 17, 2024 that led R1 to the emergency room, which facility failed to report to CCLD. LPAs tried to contact Administrator, but was not able due to phone went to voicemail. ADM gave permission for Jezrael to sign the report.
*An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *
Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction