Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint investigation findings and conducted case management. LPA met with House Manager, Tanya Barreto after authorization via phone with Administrator Sheri Lott for staff to sign. There was 3 staff with 4 clients when LPA arrived. The purpose of this case management is to follow up on issues found during a complaint investigation.

While conducting investigation into allegations of complaint 21-AS-20250602155927, it was revealed through multiple staff interviews and facility records that on 11/14/2024 there was only one staff on PM shift from approximately 11:20pm until approximately 12:00 am, during which time a client was up and sustained an injury to their forehead.

LPA cited facility on 8/21/2025 for only having 1 staff who was still there from the overnight shift (NOC) with 4 clients. LPA was informed other NOC shift staff left at approximately 8am. The morning shift staff did not arrive until approximately 9:15am.

***$250 civil penalty assessed for repeat of citation 85065.5(a)(1) in less than 12 months.

Community Care Licensing will be requesting an office meeting to discuss areas of concern.

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.