Facility Evaluation Report

Licensing Program Analyst (LPAs) Sara Martinez and Janette Romero conducted an unannounced case management visit to address the following the deficiencies observed on 10/29/2024 visit.

LPAs observed the kitchen refrigerator to be locked with what appeared to be a stainless-steel chain and laminated steel shackle keyed padlock around the door handles. LPAs observed a chain and lock around the handles of the kitchen cabinets. Staff present reported they did not have master lock key on the premises to unlock the refrigerator. LPAs also observed the pantry to be locked with a smaller chain and master lock. When LPAs returned to the facility the lock on the two pantry cabinets and the refrigerator.

Additionally, during a record review of Client 2’s admission agreement signed and dated 8/28/2024, subsection 5(A)3 indicates clients will receive an eviction notice if they do not attend day program Monday-Friday. This poses a potential personal rights to clients in care. A deficiency will be issued under Title 22 Regulation 80072(a)(3) along with a plan of correction.

Licensee reported Client 1 (C1) eloped from the facility on 10/2/2024, 10/7/2024, and 10/14/2024 and the facility did not report C1’s absence to Community Care Licensing. During today’s visit, Staff 1 handed LPA a written incident report reporting C1’s absences on the dates noted above, which does not meet the reporting requirements of providing the licensing agency with a written report within seven (7) following the incident. This poses a potential health, safety, or personal rights risk to clients in care. A deficiency will be issued under Title 22 Regulation 80061(b)(1)(E) along with a plan of correction.

An exit interview was conducted, and a copy of this report, LIC 809-D, appeal rights, LIC 811 was provided to Eva Bruce.