Facility Evaluation Report

At approximately 1:35PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Staff Member, Gustavo Carvajal, and Administrator, Rodrigue Ndomo. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 05/06/2025. Report stated that on 05/02/2025, facility staff did not administer insulin based on C1's sliding scale. Report stated that based on C1's blood sugar level, facility staff was to administer 2 units of insulin but did not. Facility made all appropriate notifications per regulation (deficiency cited, LIC809D, regulation 80075(b)).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

***An immediate civil penalty assessment in the total amount of $250.00 has been issued for a repeat violation of Regulation 80075(b) within a 12 month period. Deficiency last cited on 11/21/2024. (See LIC421FC).***

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC421FC (Civil Penalty), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.