Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen was at facility delivering findings of a complaint investigation and conducted a case management. LPA met with Licensee/Administrator Janet Kirby. The purpose of this case management is to follow up on issues found during a complaint investigation.

On 1/23/2024 while opening complaint (21-AS-20240119085541) investigation, interview with Licensee revealed all client documents for (C1) were sent with them in the ambulance PM of 1/16/2024. Title 22 Regulation 80070(g) requires facilities to retain clients records for at least three (3) years following termination of service to the client.

The facility also did not report or submit required incident report (LIC624) to Licensing Agency, which per regulation was to be done within 7 days of following the incident occurrence. 80061(b)(1)(E).

Facility is being cited today for the above 2 violations.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.