Facility Evaluation Report
Capacity10
Census7
Date signed01/01/2026 04:10:34 PM
Name of licensing program analystVadim Gorban
Name of licensing program managerBrenda Chan
On 12/30/25, Licensing Program Analyst (LPA) V Gorban conducted an unannounced case management visit. LPA met with house manager, administrator designee Shawniee Jackson was notified of licensing visit.
This case management visit is being conducted based on incident report dated 10/28/25 where R1 have not received medication as prescribed. Resident R1 Deficiency has being cited on the attached 809-D in accordance to California Code of Regulations, Title 22, Division 6.
An exit interview was conducted. A copy of this report and appeal rights was provided to house manager, whose signature on this form confirms receipt of this report.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction