Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert did a follow-up visit regarding the allegation that Staff did not provide adequate supervision to residents in care. LPA met with Staff #1 and spoke with Administrator (AD) Yesenia Menjivar via phone regarding the purpose of the visit.

LPA observed one client sleeping in the bedroom. There are a total of four clients who reside at this residence but three attend Adult Day Program (ADP). The staffing ratio is based on the level of the home. This is a level 2 home with four clients. This level of home receives approximately 172 hours per week which is then divided by the staff members. The facility is able to determine where the hours are needed most but there is always one staff member working per Personnel Report (LIC 500). Thus, in the afternoons when clients return home from ADP, there should be more staff members working as needed.

LPA spoke with AD Menjivar regarding the LIC 500 and reiterated that the staff member scheduled should be focused on the clients. If child care of school pick-up errands occur, the scheduled staff member is to remain as scheduled. The person who resides in the home is not scheduled until the afternoon and is available to run child care errands, as needed. Currently staff are scheduled from 6am to 3pm, 4pm to 11pm and 11pm to 6am. The AD is also on site from 10am to 6pm. AD was advised via Technical Advisory, to ensure staffing covers all hours so the afternoon staff member hours will change to 3pm to 11pm.

AD Menjivar will submit updated LIC 500, Staff Policy and Procedures and training regarding staff scheduled hours and duties by end-of-business on August 28, 2025. Families of clients will also be informed of any children present in the workplace and ensure that scheduled staff's full attention is on the clients in care.

Based on LPA observations, record review and interviews, no deficiencies are being cited and the allegation above is Unfounded per Control Number: 22-AS-20250812134523 An exit interview was conducted with Staff #1 and a copy of this report, LIC 811 and Technical Assistance LIC 9102-TA was provided to the facility.