Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/21/24 at 1:30p to conduct a Case Management visit. LPA met with Florencio Ballesteros and stated the purpose of the visit.

LPA toured the facility to observe bedroom #1 to have an enclosed entry way to the bathroom which is different from the floor plan submitted to Community Care Licensing (CCL) and Regional Center.

LPA requested a copy of the building permit and floor plan. Florencio stated that the documents were provided to CCL, however, LPA Brown did not locate the documentation.

LPA also observed the Licensee removed the mudroom and made the walk-in-closet into a staff room with the connecting bathroom. Bedroom #1 occupant is to use the bathroom # 3.

LPA also observed that the Licensee did not request a waiver to allow resident in bedroom #1 to have a bed without a frame.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.