Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced annual required visit. LPA arrived at the facility and was greeted by staff. LPA met with Administrator Mathew Carver and explained the nature of the visit.

LPA along with AD toured the facility at 9:10 AM. LPA toured the physical plant and reviewed facility documentation. The facility is made up of a one-story campus. The facility houses staff offices, clinical offices, a reception area, three bathrooms, a courtyard and a renovated barn for group therapy.

The facility does not store or provide food. Clients maintain their own medication and finances. Water temperature measured 110.1 degrees F. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts emergency drills twice a year with the last drill conducted on 08/20/2025. LPA verified fire alarm system was last serviced on 09/22/2025. LPA observed the emergency food and water supply. Outside grounds were toured. The facility provides a large space for gatherings. Additional offices and spaces are accessible from the courtyard. The courtyard was clear of hazards. The facility provides therapy sessions for clients. LPA reviewed four staff files and five client files. Annual training records were not documented in three out of four staff files. The remaining staff file did not include documented new hire training records. Three out of five client files did not include evidence of TB testing.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.