Facility Evaluation Report

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting a Case Management Visit, regarding a request for an exception of furniture use in a client's bedroom. LPA Maldonado met with staff Jazzmin Arrant, and explained the purpose for the visit. Jasmine phoned Administrator, Jerome Estanislao, to inform him of the visit.

Per the facility required annual inspection conducted on 02/04/2023, by LPA Kimberly Ramirez, the facility was cited for C1's bedroom missing a chair, lamp, and dresser. After LPA Maldonado discussed the matter with Jerome, he explained that C1's Individual Program Plan (IPP) indicates that due to C1's self-injurious behavior, the furniture had to be removed. This was a recommendation from C1's physician, and the placement agency was in agreement with the recommendation. He also stated that the supporting documentation was previously submitted to LPA Ramirez, however LPA Maldonado had no knowledge. Jerome provided the following documents to LPA Maldonado on 05/04/2023 for review:

Letter of Support from San Gabriel/Pomona Regional Center

Letter of support from C1's relative, who is involved in C1's care

Recommendation from C1's Primary Care Physician (PCP) to remove furniture

During today's visit, LPA Maldonado conducted a tour of the physical plant with staff Jazzmin, with special focus on Client# 1's (C1) bedroom. It was noted that C1's bedroom did not have a lamp, dresser, or a chair. Per review of C1's PCP's notes from a visit on 2/11/23, it is noted that the PCP has recommended the side tables (drawers), lamp, and chair be removed from C1's room due to safety concerns. After review of all documents, LPA will approve exemption for removal of the furniture from C1's room, and an Exception Letter will follow to be provided to the facility.

Exit interview was conducted and a copy of this report was provided.