Facility Evaluation Report

On 11/24/25 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Direct Support Professional, Kye-Shanna Manns, explained reason for visit and was permitted entry into the facility. Administrator, Itaska Mask arrived a short time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 1 resident was present during time of visit.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced on 2/25/25. Last fire drill on conducted on 10/16/25. Resident rooms observed to have the required furnishings and with adequate lighting. Medications were located in locked hallway cupboard. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: 1 of 1 resident file reviewed did not have the required documentation. Facility did not implement measures to protect residents in care from items posing a danger. Deficiencies cited per California Code of Regulations, Title 22. Deficiencies are being cited on the attached 809D.

LPA requested the following documents to be submitted to CCL by 12/5/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with Administrator, Itaska. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to Administrator. TSP was offered and accepted.