Facility Evaluation Report
Capacity16
Census12
Date signed06/10/2026 01:55:58 PM
Name of licensing program analystJose Gary Tan
Name of licensing program managerTroy Agard
Licensing Program Analyst (LPA) Jose Tan conducted an unannounced case management visit to this facility to issue deficiency for reporting requirement. During the course of the investigation of complaint control no.: 31-AS-20260602081351, LPA discovered that the facility did not submit an Unusual Incident Report (LIC 624) when the water heater and air conditioning on the 2nd floor broke down affecting the residents.
Citation issued. Appeal rights discussed and given.
Exit interview conducted. Copy of this report issued.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction