Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for a case management visit. LPA was greeted and granted entry by Administrator, Charmaine Sims, who was informed of the purpose of the visit.

An incident had been reported to the licensing agency for suspect abuse on SOC341 for Client #1 (C1). At the time of the visit a walk through, interviews and records reviews were conducted pertaining to the report. No health or safety issues were observed during the time of the visit.

A file review was conducted on the facility, interview with staff and record review of C1's record. LPA found that incident reports had not been sent to licensing for incidents involving C1 such as AWOL, medical visits, and police visits to the facility. Therefore based on the above the facility will receive a deficiency for reporting requirements. Deficiency was reviewed and plan of correction was created with administrator.

An exit interview was conducted where this report along with LIC811, 809D, and appeal rights were reviewed and provided to Administrator, Charmaine Sims.