Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit and concurrently conducted a case management visit to the facility and provided Technical Advisory’s (TA). LPA Lopez identified herself and was granted entry by Fred Sams, Administrator. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Administrator Sams. Licensee Rose Sams and Administrator Leilani Sams later arrived and joined the visit.

During the visit, LPA requested and obtained records. In review of records, LPA observed that client #1 (C1 - see LIC811 Confidential Names list) did have an IPP and Needs and Service Plan. Records show the facility has been providing C1 with behavioral services. LPA reviewed Title 22, Division 6, Chapter 1 and 6, Article 6, Section’s: 85068.1 Admission Procedures, 80068.2 Needs and Service Plan, 85068.3 Modifications to Needs and Service Plan, 85068.5 Eviction Procedures, 85122 Emergency Intervention Plan, 85165 Emergency Intervention Staff Training, and 85161 Emergency Intervention Documentation, with Licensee and Administrator's Sams'. Technical Advisory notices were given during today’s visit. No deficiencies were cited.

An exit interview was conducted with Licensee and Administrators' Sams'. A copy of this report, Confidential Names list (LIC 811) and Applicant/Licensee Rights (LIC 9058 03/22) were provided to Licensee Sams at the conclusion of the visit. The signature below confirms the documents were received.