Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 03/11/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Tina Shalaby arrived during the visit.

*Deficiency cited under Title 22 Regulation 87355(e)(3) pertaining to Criminal Record Clearance has been cleared. Licensee associated noted individuals. Licensee has complied with the terms of the POC.

*Deficiency cited under Health and Safety Code 1569.695(c) pertaining to Emergency Drills has been cleared. Licensee provided proof of drill conducted on 03/20/2025. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87412(c) Pertaining to Personnel Records has NOT been cleared. Licensee has not conducted required annual training. Licensee has not complied with the POC.

*Deficiency cited under Title 22 Regulation 87456(a)(3) Pertaining to Evaluation for Suitability of Admission has been cleared. Licensee obtained medical assessment. Licensee has complied with the POC.

Licensee addressed items on the advisory notes issued on 03/11/2025.

Based on the observations made during today's visit, the following violation IS being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.