Facility Evaluation Report

On November 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced to deliver an amended report for a case management visit on November 7, 2025, which was a follow-up visit for an incident report received by Orange County Regional Office on November 6, 2025. LPA also conducted a Case Management – Other visit for the purpose of attempting to inspect and audit all resident records for Resident 1(R1), that were not available during the previous visit. LPA introduced self and stated the purpose of the visit to Executive Director (ED) Melanie Washington.

During today's visit, at 3:15m, LPA requested full access to R1’s resident paper and electronic records. At 3:40pm, ED stated her Licensee will not permit full access to electronic resident records. ED offered to sit with LPA to review all electronic resident records. ED stated any documents requested could be printed. LPA explained that LPA needed to be able to access and review records independently to determine which documents needed to be inspected and reviewed for R1 and all residents. LPA requested to review the electronic system with staff while ED continued to request LPA electronic access from Licensee. During review, the following records were received: Evaluations dated July 19, 2024, August 15, 2024, February 13, 2024, and July 31, 2025, Fall Evaluation/Fall Investigation dated February 28, 2025, and Incident Report dated November 5, 2025. These documents were not received during the previous visit and are not available in the paper file and chart. At 4:15pm, LPA was informed that the electronic resident records would not be provided and LPA did not receive full access to any electronic records.

A deficiency is being cited as per Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC809-D, and appeal rights were provided at exit.