Facility Evaluation Report

In conjunction with complaint# 31-AS-20250630142546, On 11/17/25 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda met with staff member Josephine Co. The purpose of the case management is to address deficiencies observed during the course of investigation for complaint # 31-AS-20250630142546. During the facility file review LPA was not able to locate a facility file for Staff #3 (S3). LPA searched the Guardian website to verify the facility roster and could not locate S3 on the Guardian website. Due to no facility file on S3, LPA was not able to search and check if S3 has a current fingerprint clearance. Interview with Staff #3 stated that they started working at the facility since September of 2025. S2 also indicated that S3 assists and works at the facility from time-to-time. LPA expressed to Administrator the importance of making sure that staff is fingerprint cleared and associated to the facility prior to working and providing direct care and supervision. A civil penalty will be issued. Administrator was also advised that all staff have to have a facility file and it needs to be readily available for review. A citation will also be issued for not having a file for S3.

Citations issued. Exit interview conducted. Copy of report provided to designee.