Facility Evaluation Report

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management – legal/non-compliance visit and met by Jenoveva Avalos and Angel Leaupepetele, who are the case managers. Program administrator has a prior commitment during the time of inspection. Angel Leaupepetele was authorized to sign report by Regional Director (RD) Merita Amituanai . Authorization was sent to LPA via email.

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 12/27/2024.

During the visit, LPA toured the facility with staff Including but not limited to the kitchen, dining and activity areas of the facility. LPA conducted an interview with 5 staff.

Based on the non-compliance plan on 12/27/2024, the licensee will develop a plan ensuring that staff are protecting safety, health, morals, welfare of the participants. Participants are accorded their personal rights and free from any form of abuse, which includes staff training on topics such as personal rights, abuse, mandated reporting. Licensee and administrator's plan in operating the facility according to regulations that ensure the facility provides the care and supervision, and meet the client's needs. Licensee to administer training to staff on the protocol in seeking medical attention.

LPA conducted a file review of 10 staff record and observed that training for the following were provided; client's personal right, SOC341A, standards of conduct, safety orientation, safety violations, first aid/CPR, mandatory sexual harassment prevention and client abuse statement (zero tolerance policy), Training is in compliance on the topics as stated above.

No deficiencies were cited during today's visit based on CCR Title 22. An exit interview was conducted with Angel Leaupepetele, authorized representative/case manager and a copy of the report was provided.