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, kitchen, bathroom, staff break room, storage, laundry room, office, exterior, and transportation vans. LPA observed 2 out of 4 wheelchair transportation vans with the PD. The transportation vans has wheelchair safety procedures and diagrams posted on the back door. LPA observed the staff were provided in-service training on wheelchair training dated 11/25/2024.

The facility completed in-service training with staff to include SIR reporting, 911, and client rights dated 01/07/2025; and mandated reporting, job descriptions, wheelchair loading and unloading dated 05/08/2024. Majority of the facility staff were provided Crisis Prevention Institute (CPI) training in March 2025 which is valid for 2 years.