Facility Evaluation Report
Capacity199
Census163
Date signed12/04/2025 01:46:07 PM
Name of licensing program analystMariana Agban
Name of licensing program managerNichelle Gillyard
In conjunction to the complaint 31-AS-20251201143417 Licensing Program Analyst ( LPA) Mariana Agban conducted a Case Management Deficiencies Visit. During the course of investigation, it was confirmed that Executive Director did not submit Special Incident Report (LIC 624) for Resident#2(R2) hospitalization on 11/23/25 to CCL. LPA conducted a file review and didn't observe any reports on file for R2.
Exit Interview Conducted. Citation issued. Appeal rights given. Report signed and delivered.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction