Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to follow-up on several Unusual Incident Reports received in our office. LPA was greeted and granted entry and met with Edgar Vega, Direct Care Supervisor (DCS), and explained the purpose of the visit.

LPA toured the facility and observed the kitchen cabinet doors were destroyed. DCS informed LPA that the new cabinets have been ordered. LPA spoke with three of the clients in which one was leaving for a medical appointment. The fourth client was taking a nap.

The following documents were obtained from today's visit. Client #4 (C4)'s Adult Brief Check Log, Daily Meal Log, 24-hour Intake and Output Record, Bowel Movement Log and Ambulation Tracker. LPA spoke with staff regarding being able to communicate with C4 using the PIcture Exchange Communication System (PECS). Staff #1 (S1) and DCS shared C4 has quickly learned how to use PECS and the Self Injurious Behaviors (SIB)s have decreased.

LPA inquired about the exception letter for the Gastrostomy (G-tube) client who was admitted on April 22, 2025 and an exception letter was not received by the Department; prior to the client's admission to the facility. A deficiency will be cited. LPA obtained staff training regarding Gastrostomy Tube Competency for five staff members who were trained by Registered Nurse.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Edgar Vega, Direct Care Supervisor and a copy of this report was given to the facility along with a copy of the LIC 811; LIC 809-D and Appeal Rights.