Facility Evaluation Report

On 10/01/25, Licensing Program Analyst (LPA) Villegas conducted a case management visit in response to Special Incident Report submitted to CCLD on 09/20/25 for incident occurring on 09/12/25; regarding Client #1 (C1). LPA met with Administrator as the purpose of the visit was explained.

During case management visit LPA Villegas obtained copies of the following records for C1: (Face sheet, Admission agreement, Consent forms, Physicians report, Needs and service plan, Medication administration records (MAR) for September 2025, (MAR for August 2025 to be faxed by 10/02/25) Unusual incident report, and Eviction notice. During visit LPA also obtained copies of the client roster and staff rosters. On 10/01/25 LPA conducted interview with Administrator.

Due to insufficient information available at this time, the above allegations need further follow-up.

Exit interview conducted, appeal rights explained, and a copy of this report was provided to Administrator.