Facility Evaluation Report

This Case management-deficiency visit was conducted in conjunction with the Case management- Incident follow up visit to address the deficiencies noted at the facility that were unrelated to an incident investigation.

On 8/24/2022 Licensing Program Analyst (LPA) Tihesha Smith, Licensing Program Manager (LPM) Naira Margaryan, along with Quality Assurance Manager (QAM) Venus Rodriguez-Khorasani, and Service Coordinator Cristina Perez from North Los Angeles County Regional Center (NLACRC) conducted a joint case management visit to the facility.

LPA Smith was greeted by Staff Jones Odogwu and the purpose of the visit was explained.

During the visit the following was observed:

PHYSICAL PLANT: The garage had a broken lock on the door, a broken door frame, and broken cabinets. The hallway walls and doors were stained and unkept.

CLEANING SUPPLIES: Cleaning supplies were accessible in the garage and laundry room. All cleaning solutions was removed and placed in an inaccessible closet that was also the medication closet.

FOOD SERVICE: The facility did not have a supply of nonperishable foods for a minimum of one week or fresh perishable food for a minimum of two days on the premises. There was rotten food in the refrigerator.

STAFFING: During the visit there was four staff on shift in which five should be on shift. The fifth staff was shopping and servicing the facility van. When asked who the lead was the staff was not sure. Staff 3 (S3) stated they were lead, but they had only been working at the facility for approximately three weeks. During interviews staff had limit knowledge about their roles and responsibilities for the day. Administrator confirmed that there was a high turnover of personnel, and it impacted the facility.