Facility Evaluation Report

At approximately 1:00 PM Licensing Program Analyst (LPA) Elias Magdaleno arrived for the purpose of conducting a Plan of Correction (POC) visit and met with Tracy Skillman, Housemanager. Housemanager had to leave for a preplanned meeting, Executive Administrative Lead (EAL) Judy Johnson was designated to sign in his stead.

At approximately 1:10 PM LPA conducted a review of three (3) resident records. Client 1 (C1) and Client 2 (C2) did not have a physicians report. Deficiency cited.

At approximately 2:00 PM LPA conducted review of two (2) staff records. All required documentation present.

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided.

Exit interview conducted with EAL, whose signature on form confirms receipt.