Facility Evaluation Report

At approximately 1:15 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to follow up on a self-reported incident received by Community Care Licensing (CCL) on 09/08/2025 and met with Administrator Charmaine Infante. The incident involved a client in care who attained a key to a staff member's room and was found naked on the bed of the staff member. Administrator revealed that a follow up conservation with the client deemed the client had made access to the staff room on several occasions prior.

Administrator reports staff room keys are no longer centrally stored and cannot be accessed by clients in care and staff rooms continue to be locked. Staff now carry their own room keys at all times.

Review of client's LIC602 and Individual Program Plan give no indication that the above behavior was expected and facility have increased their observation for behaviors that are not acceptable in the home.