Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 11/08/2023. LPA identified herself and was granted entry by Jolin Ly, caregiver. LPA met with Dominique John Mase, Licensee, and discussed the purpose of the visit.

During today’s visit, LPA obtained Licensee’s signature on the amended report LIC 809 dated (01/24/2024) and deficiencies were issued on the attached LIC809-D. Please note that Advisory Notes – Technical Assistance (LIC 9102TA) were issued in error.

An exit interview was conducted with Licensee Dominique Jonh Mase, to whom a copy of this report, the amended report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.