Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Program Director (PD), Michele Pagsisihan.

The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 12/12/2024. During visit, LPA toured the facility with PD to include the activity rooms, office, staff break room exterior, and transportation vans. LPA observed 1 out of 4 wheelchair transportation vans with the PD which has wheelchair safety procedures and diagrams posted on the back door. PD states all the transportation vans has wheelchair diagrams posted on the back doors. PD states the transportation vans are also being inspected yearly. LPA observed the staff were provided in-service training on wheelchair loading and unloading training (dated 06/02/25) and vehicle accident procedures and when to call 911 (dated 09/20/2025). The facility staff also completed in-service training to include SIR reporting (dated 07/30/25), client rights (dated 07/30/2025), and mandated reporting (dated 05/21/25). Majority of staff were provided Crisis Prevention Institute (CPI) training in March 2025 which is valid for 2 years. Facility is working on providing 4 new staff CPI training.

The Program Director was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 12/12/2024 to ensure the facility stays within compliance of Title 22 regulation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Michele Pagsisihan and a copy of the report was provided.