Facility Evaluation Report

This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 09/15/22 regarding Resident #1 (R1). LPA met with Program Director (PD) Julian Hernandez and discussed the purpose of the inspection.

The incident report states the following: on 09/13/22, the face sheet containing R1’s confidential information was stolen from the trunk of the car of a facility staff while the car was parked outside the staff’s home.

During a previous inspection on 09/20/22, LPA interviewed PD and Administrator (AD) Sarah Glover and requested and reviewed the facility’s Policy and Procedures Driver Roles and Responsibilities. PD and AD provided the following information: facility staff, using their personal vehicles, pick clients up from their homes, transport them to the facility where they provide services to the clients, then return the clients to their homes. Facility staff maintain copies of the face sheets for the clients they are serving as reference to the clients’ addresses as well as for medical emergency contact information for emergencies. The facility’s policy is that the face sheets should be locked in the staff’s car, either in the trunk or the glove box. LPA reviewed the facility’s Policy and Procedures Driver Roles and Responsibilities which states “Client documents should be stored in a locked area when having confidential information (Glovebox, Trunk).” PD stated that R1’s face sheet was stolen while the facility staff was following the facility’s policy and that the policy is for the face sheets to be locked in the staff’s vehicle overnight. PD stated the facility will explore changing the policy to ensure this situation does not occur again in the future.

During today’s inspection, LPA interviewed PD who stated that the facility explored changing the facility’s policy but decided not to change its policy for face sheets to be locked in the staff’s vehicle overnight. LPA provided technical assistance regarding securing confidential information and ensuring the facility has specific processes for staff to follow.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.