Facility Evaluation Report

Licensing Program Analysts, (LPA) Leizl de la Cerra and LPA Leslie Ngo-Castaneda made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 07/10/2024. LPA met with program director, Gary James, and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Client files:LPA conducted a file review for five (5) clients between 11:00AM to 1:00PM. While reviewing the records LPA observed various forms in client's files that were incomplete and/or missing required information such as admission agreement and physician's report.

Staff files: LPA conducted a file review for ten (10) staff members between 12:00 PM to 1:00PM.

For the deficiency observed (refer to LIC809-D). Exit Interview Conducted. Appeal Rights and a copy of this report issued.