Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management inspection and met with Licensee, Povi Wagner.

CCL obtained information from an outside agency about an incident were participant (P1) was observed sitting by themselves with their shoes off, their shirt wet with their drool, and not engaged in any activities. When day program staff were asked, they had no documentation of activities the P1 was engaged in. They also did not have a schedule of activities for P1 or the other participants on file.

During today's visit, Licensee confirmed that this incident occurred and provided information that the day program prior to the pandemic used to develop a monthly schedule of personalized activities depending on their individual needs. However, they have been working on re-instating them, developing individualized schedule of activities for all on-site participants taking in considerations any changes of condition. Day program also provided LPA with P1's schedule of activities dated 3/23/23. Per Licensee, P1 resumed attending the day program on 11/08/22, but due to medical reasons they have not been attending to day program as scheduled two times per week. Therefore, it had been difficult to fully re-instate their individualized plan. Licensee informed LPA that the individualized scheduled of activities for all on-site participants will be complete by April 3, 2023 and agreed to submit a self-certification form (LIC90988) to notify LPA that such process is complete to get back in compliance with regulation.

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.