Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit as part of the monitoring compliance plan discussed during the Noncompliance Conference agreement. The purpose of the visit was discussed with Administrator Eduardo Alvarez. LPA conducted an interior and exterior physical plant tour of the facility and reviewed facility records.

A total of 8 staff, 2 lead staff, and Administrator were observed during the AM shift. There are currently 40 staff employed. A reduction of staff was noted. Administrator stated that some staff did not complete RBT training requirements, were terminated due to attendance, or voluntarily left.

Staff Schedule [Nov. 17, 2024 - Nov. 30, 2024] and Weekly Assignments records were reviewed. Staff to resident ratio is met. Effective October 1, 2024, night shift staff ratio was decreased per DDS and ELARC recommendation.

Employee Conduct and Discipline/Employee Relations: "Personnel 'Intimate' Relationship Policy" was implemented on 9/25/2024. A copy was reviewed and obtained.

Facility certified another staff as back-up CPI certified training instructor. Proof of Certified Instructor Identification Card for staff Derrez Coleman was reviewed. Certification date 11/22/2024. On 11/19/2024, Lead RBT Adriana Harbin completed the Eastern Los Angeles Regional Center Residential Services Orientation Program.

The Emergency and Disaster Plan was reviewed in order to ensure the Emergency Power Outage Plan was added. On 9/5/2024 the facility had a power outage for approximately 8 hours. The facility was notified in advanced and Administration staff planed accordingly. However, the Emergency Disaster Plan did not include an Emergency Power Outage Plan. A copy of the plan was obtained.

The exterior surveillance cameras were removed on 9/13/2024.

The facility hallway walls have large areas that have been damaged by staff chair use. Administrator stated a work order has been requested. Citation is being issued.

No health and safety concerns were observed during this visit. A an exit interview with Administrator Eduardo Alvarez was conducted. A copy of the report and appeal rights were issued.