Facility Evaluation Report

Licensing Program Analyst (LPA) Angelica Boyles made an unannounced Case Management visit to the facility in order to review facility records. LPA was welcomed by and discussed the purpose of the visit with Administrator Maniza Ambalada.

LPA conducted a brief facility tour and reviewed staff and resident records. Staff records reviewed revealed that there were no personnel files for Staff #1 (S1). [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Records for Staff #2 (S2) did not include criminal record clearance. A review of the Guardian background check system revealed S2 had eligible background clearance, but was not associated to the facility. Additionally, Staff #3 (S3) did not have a Health Screening Report (LIC503) on file.

Three deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809 D pages) and a Civil Penalty was assessed for the total of $500 (refer to attached LIC 421BG). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Administrator Maniza Ambalada, to whom a copy of this report, the LIC 809 D, LIC 421BG, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.