Facility Evaluation Report

Licensing Program Analysts (LPAs) Dang Nguyen and Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and identified themselves to volunteer Lisa Vance. LPA then met and discussed the purpose of the visit with Licensee Ligaya Sanders, who arrived later during the visit.

During today’s visit, LPAs toured the facility, reviewed staff and client records, and interviewed staff and clients.

Upon arriving to the facility, LPAs observed that Volunteer #1 (V1) was left alone at the facility to supervise four clients who were physically present (C1 through C4). Per interview of V1: for a period of approximately 25 to 30 minutes, there was no facility staff present at the facility to supervise or assist V1, as was required. The Licensee and another staff then arrived at the facility. Per regulation, volunteers may “not be included in the facility staffing plan” and “shall be supervised” at all times. The absence of staff to accompany V1 meant that clients were temporarily not supervised.

Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

One (1) deficiency was cited per California Code of Regulations, Title 22. An immediately civil penalty of $500 was also assessed (refer to the LIC421-IM). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted the Sanders, to whom a copy of this report, the LIC809-D, the LIC421-IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.