Facility Evaluation Report

On 03/13/23 Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Case Management with Valencia Thomas, Direct Support Provider (DSP). The case management visit pertains to a Special Incident Report (SIR) dated 02/02/23. LPA spoke to Licensee Deon Goolsby by phone and advised her of the reason for the visit.

During the visit, LPA requested the LIC 500 and advised licensee that LPA did not receive criminal record clearance for Staff (S1 and S2). LPA verified that S1 and S2 were not associated in Guardian,

-On 02/05/23 at 02:50 PM, LPA L. Holmes received an email from S3 with an attached SIR for C1 along with photos of damaged property relating to an incident on 02/02/23. The description of the report identifies S1 and S2 as staff and present at the facility with C1.

- On 02/06/23 at 09:14 AM, LPA L. Holmes responded to the above email requesting a Client Roster, Staff Roster, and proof of criminal record clearance for S1 and S2.

- On 03/10/23 at 11:55 AM, S5 provided LPA with an LIC 500 dated 08/18/22. S1 and S2 are on the LIC 500 as Direct Support Staff. Licensee provided an additional email to record for future contact.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Copy of report and appeal rights provided to Valencia Thomas, DSP