Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to cite deficiencies unrelated to a complaint investigation. LPA was greeted by, identified herself to, and explained the purpose of the visit to Assistant Administrator Tom Gilbert. Administrator Ligaya Sanders de Leon arrived during the visit.

During today' visit, LPA conducted a tour of the facility, interviewed staff and clients, and reviewed facility records.

Review of the facility records revealed that the Administrator did not have personnel records for Staff 1 (S1) and Staff 2 (S2). Interviews revealed that S1 & S2 have been working at the facility since May 2023. Review of the Department's background clearance database showed that both S1 and S2 were fingerprinted and had an active background clearance. Review of the facility records revealed that the Administrator did not have client files for clients 1, 2, 3, and 4 (C1, C2, C3 and C4) and Client 5's (C5) file did not have a current physician's report. [Administrator was provided with an LIC811 Confidential Names list to identify individuals] Interviews revealed that the Administrator did not know the location of the client files.

During the facility tour, LPA observed the facility's kitchen, which was cluttered with food boxes, drink bottles, fruit containers, and an uncovered egg carton. LPA observed insects crawling on the eggs and the food boxes by the kitchen door.

The following deficiencies are cited per California Code of Regulations Title 22 and noted on the attached LIC809-C pages.

An exit interview was conducted with Administrator Ligaya Sanders de Leon, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).