Facility Evaluation Report
Capacity98
Census66
Date signed08/18/2025 03:57:17 PM
Name of licensing program analystMariana Agban
Name of licensing program managerEva Miller
In conjunction to the complaint number 31-AS-20250811124846 Licensing Program Analysts (LPA) Mariana Agban conducted a case management- Deficiencies visit.
During the complaint investigation, LPA reviewed Internal Resident's Incident Report and observed that on 7/10/25 R2 was R2 was bleeding with a lot of bruises. LPA later confirmed that Administrator failed to submit a Special Incident Report for Resident 2(R2) to CCL. LPA conducted a file review and didn't observe Special Incident Report (SIR) on file for R2.
Deficiencies Cited. Exit Interview Conducted. Report Issued
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction