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 Lead BSP Trevor Sparkman and Assistant Program Director Cruz Mora.

The facility currently operates under a two-year probationary facility license from CCLD, the result of an 08/22/2022 Stipulation and Waiver, and Order (SW&O). 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 SW&O.

Staff interviews, corroborated by record review, essentially supported: a) licensee has a designated “Orientation Trainer” who conducts/oversees both new hire and regularly scheduled training for staff; b) licensee has a designated “Quality Assurance Manager” who meets with the facility’s program manager at least monthly to ensure trainings are completed on time; and, c) licensee has a designated “Quality Assurance Team” that conducts quarterly internal audits. Furthermore, d) quarterly internal audit results/reports are shared with the Department of Developmental Services (DDS), the San Diego Regional Center (SDRC), the CCLD San Diego Regional Office (RO), and licensee’s own corporate officers/directors; and, e) licensee’s corporate officers/directors discuss quarterly internal audit results/reports at their board meetings. They also supported that: f) licensee conducts Clients’ Personal Rights training (including topics on regulations, types of abuse, Mandated Reporting, and incident reporting) for facility staff, at least twice per year; g) licensee monitors incident reports at least monthly to ensure timely submission, h) licensee maintains required practices regarding medication management (as described in the SW&O); and i) licensee maintains required practices regarding communication between direct care staff and management (as described in the SW&O). [CONTINUED ON LIC 809-C]