Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced plan of correction (POC) visit. 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.

The purpose of the visit was to verify if deficiencies issued on 8/15/2023 had been corrected. On 8/15/2023, the licensee was issued 2 deficiencies with a correction due date of 9/15/2023. On 9/7/2023, LPA Ruiz approved a POC extension date of 10/15/2023. On 10/15/2023, the licensee submitted proof of correction to the Department.

During today’s visit, LPA Ruiz reviewed staff and client files and observed clients in care. Staff files contained personnel records, employee rights, health screening, and fingerprint and criminal background clearance. Client files contained identification documents, LIC602 Physician's Report, signed admission agreements, personal items records, pre-admission assessments and needs and service plans. Therefore, the deficiencies 80066(a) and 80070(a) have been corrected.

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