Facility Evaluation Report

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Administrator Brandon Salgado to discuss the purpose of the visit.

Today's visit was in response to the facility's self-report regarding a staffing deficit of one (1) support staff for a period of three (3) hours, from 12:00pm - 3:00pm on 05/09/2026. The administrator informed that the only part of the ratio that was affected was the support staff position. Direct client ratios and lead position remained intact. Additional managers were attempted to be utilized, however those managers were acting as ratio staff at a different facility. The staff leaving shift were unable to stay due to having already extended their shifts. Based on these circumstances the facility had exhausted their options to cover the support staff role for 3 hours.

Upon arriving to the facility LPA was informed by Lead RBT Kat Fosi that an active evacuation was underway due to a possible gas leak. LPA spoke with Administrator who informed that the propane connection had been turned off and they had not observed any gas odor. Administrator advised that management was in the process of making the additional calls and Administrator did not have additional details. Administrator will provide additional details once received.

LPA concluded the visit to support the evacuation. An exit interview was conducted with Administrator Brandon Salgado, who agreed to receiving a copy of this report and Appeal Rights (LIC9056 03/22) via email and signature via Adobe Sign.