Facility Evaluation Report

On April 21, 2025, at 12:20 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 04/10/2025 when the client (C1) was dropped at the wrong day program by the facility’s driver (S1). LPA met with the Program Director (PD), Alisha Roswall, and disclosed the purpose of the inspection.

LPA interviewed one (1) staff member: the Program Director (PD).

The PD stated that S1 had looked up the address for the Mission Bay Day Program using Google Maps and selected the first location that appeared. The Mission Bay Program had multiple locations, and S1 assumed that the client (C1) was to be dropped off at that specific location, as C1 had previously attended the program at that site. At approximately 2:00 PM, S1 dropped off C1 at the selected location, and the program accepted C1.

Later, a family member (FM) of C1 contacted the PD at the facility and informed them that C1 had been dropped off at the incorrect location. The FM stated that the program where C1 was currently located would transport C1 to the correct location. The FM did not raise any concerns or ask questions, as C1 had previously attended the other program and had an existing relationship with them. The FM picked up C1 at the end of the day from the correct program location.

On 04/16/2025, the PD spoke with S1 and addressed the incident, stating that dropping C1 at the incorrect location was not acceptable or excusable. Verbal corrective actions were taken with S1, including instructions to double-check addresses, ensure the correct drop-off location, and follow proper documentation procedures.