Facility Evaluation Report

On 07/12/22, Licensing Program Analyst (LPA) Gail Johnson and (LPA) Stephanie Cifuentes conducted a Case Management visit to follow up on the death for Client #1 (C1). LPA Johnson and Cifuentes were greeted by staff Mabel Walker. LPA Johnson explained the purpose of the visit was to gather information surrounding the death of (C1).

On 07/08/22, LPA Johnson documented the death of (C1) and called Assistant Administrator Renita Campbell. Assistant Administrator Campbell stated, (C1) passed away at the facility on 07/03/22. On 07/12/22, LPA Johnson and Cifuentes toured the facility, interviewed Assistant Administrator Renita Campbell, Staff (S1)-S2, and (C2) – (C6).

On 07/12/22, LPA Johnson requested the following documents:

· Identification and Emergency Information

· Individual Program Plan (IPP) & Individualized Behavior Support Plan (IBSP)

· Most Recent Physician’s Report / Assessment

Based on the facility tour, the licensee violated the California Code Regulations (CCR) of Title 22 sections 80087 Division 6 Chapter 1. On 07/12/22, LPA Johnson and Cifuentes observed several broken pieces of the living room tile floor, items that need to be thrown away in the backyard and the client bathroom needed to be cleaned.

Assistant Administrator Campbell stated that the facility will have the bathroom and backyard cleaned and tile floor repaired by 08/01/22. Report Continued on LIC 809-C