Facility Evaluation Report

On 11/04/25, Licensing Program Analysts (LPAs), L. Salazar and M. Vega arrived to the facility unannounced to conduct the required 10 day visit. During a file review for the 10-day required site visit, LPA Salazar observed deficiencies. LPA was greeted by Administrator, stated the purpose of the visit and were allowed entry into the facility. LPAs met with Administrator, Assisting Administrator Daniel Flores, and PLAD Leah Martinez, to discuss incidents that are being discussed for care and supervision, personal rights cited on this case management visit.

LPA conducted a facility file review and observed self reported incidents for Resident R1, Resident R2 and Resident R3. Records reviewed show Resident R1 AWOL'd from the facility 05/12/25, 05/21/25, 07/17/25, and 10/06/25. This resulted in 4 calls to Tulare County Sheriff's Office (TCSO) for assistance. R3 has AWOL'd from the facility on 08/18/25, 09/16/25, 09/29/25 (twice), and 10/21/25 resulting in TCSO being called for assistance. Interviews with Administrator Eric Morales, and Interim Administrator Daniel Flores, state residents were shadowed during the AWOLs with no injuries observed.

07/05/25 - R4 missed medications - (07/05/25, 07/06/25, 07/07/25) -Tara Allen was Administrator at this time

07/15/25 - R2 was assaulted by R3 - -Tara Allen was Administrator at this time

09/29/25 - R2 was assaulted by R3 throwing a bag of ice

10/06/25 - R1 threw bucket of mop water in R3s room

10/12/25 - R1's was throwing chairs, breaking them on the ground, resulting in TCSO being called.

10/19/25 - R3 assaulted R2 by punching them in the head twice and throwing a jacket at R2. The zipper of the jacket hit R2 between the eyebrows.

Per California Code of Regulations, Title 22, Division 6, Chapter 6, a deficiencies are being cited on the attached 809-D. If not corrected, these violations pose an immediate Health, Safety, or Personal Rights risk to persons in care. An exit interview was conducted with Administrator. A plan of correction was developed and reviewed by LPA with a due date of 11/5/25. Appeal rights and a copy of the report were provided at the time of visit.