Facility Evaluation Report

11/12/2025 at approximately 8:30am, Licensing Program Analyst (LPA) Hansen arrived unannounced to continue an Annual Required inspection that was initiated on 11/06/2025, and was greeted by Luz Maldonado, Mental Health Counselor/staff. Program Director, John Ahrens and Assistant Program Director, Suhay Rivas arrived during visit.

LPA conducted a sample review of staff records at approximately 10:00 AM and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training for 2025. Facility was unable to provide proof of CPR & 1 st Aid certification for 4 of 5 staff (S1,S2, S3, S4) records that were reviewed (see LIC809D).

LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions at 10:30 AM.

Facility is being cited today for deficiencies from initial inspection (11/06/2025) regarding Client updated care plans (see LIC809D).

Assistant Program Director will be submitting LIC200 for updated facility email and mobile contact #.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.