Facility Evaluation Report

On 05/15/25, Licensing Program Analysts (LPAs) L. Salazar and S. Hurt arrived at the facility unannounced to conduct an annual continuation visit to review facility staff and client records. LPAs were greeted by staff, stated the purpose of the visit and were allowed entry into the facility. LPAs met with Program Director(PD)/Administrator during the visit. Administrator on record is Brandy Frazier.

LPAs observed four residents home and five staff members present. LPAs' reviewed a sample of staff files and observed Staff S1 does not have a personnel file available to review. LPAs' verified S1 is fingerprint cleared and associated to the facility. S1 showed proof of TB test/clearance. Staff 2 does not have required current Emergency Intervention training.

Resident 1's (R1) recent Physicians report (LIC602) is not consistent with prior reports dated in 2019, 2021, 2022, 2023. Prior reports dated 2019-2023 have (five) primary diagnosis' / four secondary diagnosis'. R1's Physicians report dated 2024 has only one primary diagnosis, and one secondary diagnosis. 2 of 2 resident files reviewed did not have the required Regional Center written certification, which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803. R1 does not have the required annual updated Needs and Services plan in file (Individual Performance Plan or current dated Behavioral Functional Assessment).

Due to time, LPAs concluded inspection. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiencies are being cited on the attached 809-D. If not corrected, this poses an potential risk to the health safety and personal rights of residents in care.

An exit interview was conducted with PD. A plan of correction was developed by PD and reviewed with LPAs. A copy of this report and appeal rights were provided at the time of the visit.