Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Justin Griggs. LPA also met with Quality Assurance Manager Morgan Davis, who arrived later during the visit.

The facility currently operates under a two-year probationary facility license from CCLD, the result of an 08-22-2022 Stipulation, Waiver, and Order (SWO). During today’s visit, LPA conducted a general overall inspection of the facility, interviewed staff, reviewed records, and evaluated licensee’s ongoing compliance with the requirements described in the SWO.

Staff interviews, corroborated by record review, essentially supported: a) licensee has designated an “Orientation Trainer” who conducts new hire and other training for staff; b) licensee has a “Quality Assurance Manager” who meets with the facility’s program at least manager monthly to discuss training; c) licensee has a “Quality Assurance Team” to conduct quarterly internal audits; d) results of such internal audits are forwarded to the Department of Developmental Services (DDS), the San Diego Regional Center (SDRC), the CCLD San Diego Regional Office (RO), and licensee’s board of officers/directors; and, e) the board of officers/directors discuss such audit results at their board meetings. They also supported: f) licensee conducts Clients’ Personal Rights training for staff twice a year, g) licensee reviews incident reports at least monthly to ensure timely submission; and, h) licensee implemented required practices regarding medication management and communication between direct care staff and management (as described in the SWO).