Facility Evaluation Report

On 08/05/26 Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Jessica Lewis for a case management visit. The purpose of the case management visit is to address a deficiency observed during the course of investigation for complaint # 31-AS-20260731093128. The deficiency was not alleged but is related to the complaint. Entrance interview conducted.

During LPA’s record review it was observed that the facility failed to submit an updated program design to Community Care Licensing (CCL). The facility design that was originally submitted to CCL was for a level 4i design that correlates with North Los Angeles Regional Center (NLARC) facility levels. LPA observed that the facility is now operating at a level 2 design that correlates with NLARC facility levels, however this new design was not submitted for approval to CCL. LPA explained to the Administrator that CCL approved the original program design, and the license was provided due to the original program approval. LPA further explained that any changes that are made to the design must be approved by CCL prior to being implemented, therefore a citation will be issued. The Administrator acknowledged that the previous program design has changed to include verbiage for a level 2 facility. The Administrator agreed to submit the changes to CCL.

Citation issued. Appeals rights discussed and provided. Exit interview conducted. Copy of report provided to Administrator.