Facility Evaluation Report

On August 11, 2025, a non-compliance conference was conducted. The purpose of this conference meeting was to address non-compliance at the facility after being issued 3 Type A citations and 1 Type B citation. Present in the meeting was CCLD staff, including Regional Manager Alycia Rayner, Licensing Program Manager Maribeth Senty, Licensing Program Analyst Angela Hood, and facility staff, including the Administrator Tausha Smith, Quality Support Specialists Gina Renteria and Serena Rojas, District Manager Arneatha Simon, Senior Vice President Michelle Mainez, Regional Director Mauricio Villatoro, and Vice President of Operations Les Parker. The conference process was explained during this meeting.

Issues discussed during this meeting were:

The facility has stated that they will do the following to achieve continued and substantial compliance:

· Ensuring updated Individualized Behavioral Support Plans for each client

· Implemented additional training for staff and management

· Increased communication regarding clients and staff

· Implemented electronic health records for easy access

Facility agreed to write a summary regarding all new protocol that was implemented and submit to CCL by August 19, 2025.

The facility has implemented policies and procedures to ensure substantial compliance. Facility was notified that the Department may increase monitoring at the facility and the completing of the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.