Facility Evaluation Report

On 3/11/26 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Program Director, Kelly Wheeler, explained reason for visit and was permitted entry into the facility. LPA completed a tour and health and safety check on clients in care. Clients observed programming in activity rooms.

This case management visit is being conducted due to Incident Reports that were received by the department. During visit LPA completed interviews, gathered and reviewed documentation (staff schedule, staff roster, client roster, physicians reports, individual program plans, needs and services plans, case notes and reviewed video footage).

Incident 1 occurred on 2/25/26. R1 was having lunch in activity room when they began choking on their food. Staff preformed the Heimlich maneuver on R1, helping the food to become dislodged. Review of physicians report stated R1 was able to feed themselves. IPP stated mother of R1 prepares meals for R1 to have at program. There is no indication staff need to watch R1 closely while eating. Interviews with staff disclosed that R1 likes to talk during meals and has to be reminded frequently about this distraction while eating. Review of video surveillance and staff schedules show the facility had 2 staff for the 9 clients being supervised during lunch.

Incident 2 occurred on 3/9/26. R2 was having lunch in activity room when they began choking on their food. Staff preformed the Heimlich maneuver on R2, helping the food to become dislodged. Review of physicians report stated R2 is able to feed themselves. IPP stated food is prepared at home for R2 to have at program. R2 is on a chopped mechanical diet. Interviews disclosed staff will chop the food prior to R2 eating it, unless it is pasta/noodles. On this date, food was pre-chopped when check by staff. Review of video surveillance and staff schedule show the facility had 2 staff for the 7 clients being supervised during lunch.

Deficiency cited per California Code of Regulations, Title 22 on 809D. for staffing ratio.

Exit interview completed with Program Director, Kelly. A plan of correction was developed by Program Director and reviewed by LPA. If not corrected the deficiency will have a direct impact to clients in care. A copy of this report, deficiency and appeal rights provided.