Facility Evaluation Report

On May 1, 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 April 23, 2026. The incident report was regarding Client #1 (C1) leaving the property. 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 five 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 initial psychiatric evaluation, shift notes, and counselor notes for C1. LPA also reviewed the staffing for the day of the incident. Per the shift notes for C1 dated April 16, 2026, it states C1 exited the property at approximately 9:50 PM. It states that staff observed C1 leave the property and staff pursued C1 but ended up losing sight of C1 during the pursuit. Additional staff and law enforcement were then called and client returned to the property at approximately 10:45 PM without any injuries. LPA reviewed the staffing schedule for the day of the incident and observed the facility had three staff on duty, which complied with the facility's staff to client ratio. LPA conducted two staff interviews. Two out of two staff interviewed confirmed that there were sufficient staff on duty. The two staff also confirmed that staff observed C1 leave the property, and that staff pursued C1 immediately upon recognizing this.

Based on the observations made during today's visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Behavioral Health Specialist IV Brianna Graham and a copy of the report was provided at time of visit.