Facility Evaluation Report

On January 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management Incident inspection. LPA is following up on a self reported incident report that was received by the Orange County Regional Office on January 15, 2026. The incident report was regarding Client #1 (C1) leaving the property unobserved for approximately thirteen minutes. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Behavioral Health Specialist IV (BHS) Brianna Graham was notified via telephone and later arrived to assist with the inspection.

On today's visit, LPA observed three clients in care. LPA, accompanied by BHS, conducted a tour of the physical plant. LPA observed the facility to be clear of any obstructions and hazards. No health or safety concerns were observed. LPA additionally reviewed and obtained pertinent documents for the incident which included the medical assessment and risk assessments for C1. LPA was unable to conduct an interview with C1 since C1 discharged from the facility on January 21, 2026. LPA also conducted two staff interview. Two out of the two staff interviewed confirmed the information on the incident report was accurate and that C1 left the property unobserved by staff.

Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Behavioral Health Specialist IV Brianna Graham. A copy of the report and Appeal Rights were provided.