Facility Evaluation Report

At approximately 1:30 PM Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Case Management - Other visit and met with Executive Director Candice Moses.

The purpose of this visit was to gather further information regarding an Incident Report and subsequent Death Report received by Community Care Licensing (CCL) on 6/26/2025 and 6/27/2025 respectively. LPA is following up due to potential discrepancies between Death Report and the Death Certificate that was later received by CCL.

LPA is also following up on a reported change of Administrator from Samuel Deguzman to Candice Moses. LPA has requested the following documents be submitted by 1/12/2025:

Copy of active and current Administrator Certificate

Copy of Board of Directors Resolution Meeting Minutes Signed

LIC308 - Designation of Facility Responsibility

LIC503 - Health Screening including proof of Negative or Inactive TB test results.

No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.