Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Case Management inspection and met with staff, Marylis Gachu . Licensee/Administrator, Darian Hall was available by phone.

LPA has returned to review staff files, that were unavailable during the Annual Continuation inspection dated. September 19, 2023 including, but not limited to, First Aid and CPR Certificates and the Centrally Stored Medication Log.

Review of records show that three of three staff have active First Aid and CPR Certificates. One of three staff have the results of a TB test. Three of three staff do not have a health screening form in their file.

LPA reviewed the Centrally Stored Medication Log for 2 of 3 clients as the third client did not have a completed Centrally Stored Medication Log. The medication on hand does not match the Centrally Stored Medication Log. LPA discussed with staff the importance of documenting missed medication and ensuring that the Centrally Stored Medication Log is filled out entirely.

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.