Facility Evaluation Report

Licensing Program Analysts (LPAs) Dang Nguyen and Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection which they began on 12/28/2023. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Ligaya Sanders.

For the annual inspection, LPAs toured the facility, reviewed staff and client records, and interviewed multiple staff and multiple clients. [See LIC811 Confidential Names List for a description of person identifiers used in this report.]

During facility tour, LPAs observed that Licensee did not ensure that cleaning chemicals and laundry detergents were inaccessible to clients, as required.

Record review, corroborated by licensee and staff interviews, showed: Licensee did ensure that the facility’s present Administrator on record, Staff #1 (S1), was currently certified by CDSS, as required. Also, no other staff at the facility held such certification. For 3 of 3 direct care staff [S1, Staff #2 (S2), Staff #3 (S3)], Licensee did not ensure that each had current First Aid Training from a qualified agency, as required. For 3 of 6 clients [Client #1 (C1), Client #2 (C2), and Client #3 (C3)], Licensee did not maintain on file written proof of a negative tuberculosis test result, as required. Also, Licensee did not perform quarterly disaster drills with direct care staff on each shift, as required.