Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a Case Management inspection to cite deficiencies observed from an inspection conducted on 3/14/24. LPA was greeted and granted entry into the facility by DSP Lazara Torres. Administrator Noel Villegas joined the inspection for the narrative review.

LPA asked to be shown the client bedrooms. LPA noted a client's bed is on a box spring on the floor in one of the client rooms. AD stated the client's IPP indicated that the bed must be close to the floor for safety due to seizures. AD also stated the client's conservator requested the bed be placed close to the floor for safety. The facility has a bed frame available in the client's room. AD stated that, per the client's Interdiscplinary Team Agreement, the mattress and box spring are not placed on a bed frame, because it too high.

Based on interview with AD and FAS file review, LPA determined the facility did not submit to Community Care Licensing a waiver request to put the bed and box spring on the floor. A deficiency is being issued on this day.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided.