Facility Evaluation Report

On 02/18/2025 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct an unannounced Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office and as a result of that NCC, the facility was placed on a two year compliance plan.

LPA arrived at 10:00 am and was greeted by staff member. Staff member called and spoke to Administrator who stated that they would arrive shortly. Administrator arrived shortly after, and LPA explained the purpose of the visit.

Staff member informed LPA that two (2) out of three (3) clients were currently in their day programs. One (1) client was observed in their room resting.

Today’s focus was Care and Supervision, Food Service, Medication Documentation, Building and Grounds, Limitations on Capacity and Ambulatory Status, and Personal Rights.

LPA conducted a physical plant tour and observed the facility maintains room temperature at 68°F .

Kitchen: The kitchen was clean and clear of clutter. LPA observed a two day supply of perishable and a seven day supply of non-perishable food at the facility all properly stored. LPA observed sharps or knives properly stored in a locked kitchen cabinet inaccessible to clients in care. Properly labeled medications were locked in one of the kitchen cabinets. The fire extinguisher is in the kitchen and was observed fully charged with last service date 12/02/2024. Hot water temperature was measured at 107.6° Fahrenheit.