Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Diana Mendez, Program Manager. The purpose of this Case Management Visit is to conduct a follow up on an incident report submitted to Community Care Licensing (CCL) on April 23, 2026 from another agency case# SR260003910 involving participant (P1) that occurred at a different location, but incident was not reported to licensing agency.

Per incident report, on 4/15/26 at approximately 8:00am, P1 was brought to the day program, while P1 was at the day program, there were concerns due to P1's breathing, so they transport them to the hospital for further evaluation. During today's visit, LPA conducted interviews with day program staff (S1) who stated that P1 arrived around 9-9:30am when they arrived to day program, staff noticed that they were warm, so S1 took their temperature and noticed that they had a fever of 100 degrees, called P1's home to notify them about it, drafted a small narrative describing the incident, the home staff arrived within the hour to take P1 to the hospital for further evaluation, but there were no incident reports issued to the licensing agency notifying them about it. According to administrator, they did not have knowledge that they needed to submit an incident report to licensing when they send any participant home sick. LPA explained reporting requirement regulation 82061 to Program Manager.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Program Manager and a copy of this report was given.