Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA was granted entry after completing the Coronavirus 2019 screening procedure. Via phone, LPA spoke with Administrator (AD) Ken Leonard stated the purpose of the visit.

On August 1, 2022, Community Care Licensing Division (CCLD) Orange Office, received an incident report from the facility describing that on July 30, 2022 Client 1 got out of the facility unattended.

On August 2, 2022, LPA Marin conducted an unannounced case management visit. During the visit, LPA observed four clients in care with two of whom were picked up by respective day programs. LPA toured the interior and exterior portions of the facility, and conducted interviews and file review.

Based on observation, interviews and file review, the following deficiencies were observed:

Client 1 got out of the facility unattended or unassisted between 10:00 PM to 8:20 AM.

At 10:20 AM and 10:21 AM (August 1, 2022) auditory exit alarms installed on the main door and Client 2 exit door were observed non operational.

For this visit, LPA Marin toured the interior and exterior portions of the facility. LPA observed one staff with no clients on the floor. LPA tested the auditory exit alarms installed in all three exits and they were observed to be operational.

Based on the deficiencies observed, LPA Marin issued citations per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted a phone exit interview with AD Leonard. LPA discussed the deficiencies observed, citations issued, the appeal rights, and the civil penalty assessment form. AD granted permission for staff to sign and receive the report. LPA left copies of this report, LIC809D (deficiency), cited regulations, appeal rights, and civil penalty assessment form in the facility.