Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management inspection visit, and met with Administrator (ADM) Tammy Lu.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a meeting held on 06/21/2022. During the meeting, licensee agreed to do the following in order to bring the facility into compliance:

1. Licensee shall develop a plan in writing describing the facility plan in properly assessing new clients and developing the Appraisal Needs and Services plan to ensure clients’ needs will be met prior to acceptance.

2. Licensee shall develop a written plan describing the staff training to ensure staff adhere to clients’ behavioral and intervention plans to meet clients’ needs.

3. Licensee shall develop a written plan describing the staff training on ensuring clients’ personal rights are not violated.

4. Licensee shall develop a written plan as an addendum to the plan of operation describing how facility shall comply with the prohibited use of manual restraint on clients in care. This shall include staff training on emergency intervention.

5. Licensee shall develop a written plan describing the facility plan in reporting incidents, be it unusual incident or communicable disease, timely to the department.