Facility Evaluation Report

LPA conducted a case management – deficiencies visit at the facility today in conjunction with unrelated complaint visits conducted at other facilities on the same physical grounds. Also present during today's visit was Department of Health Care Services (DHCS) Associate Governmental Program Analyst (AGPA) Kevin Ciacco-Rehkopf. LPA met with Program Administrator Jay Lytton at 09:14AM. Entrance interview conducted.

Record review revealed that the facility's Program Design submitted to the Department indicates "one residential counselor is scheduled for the Casa on the day shift and two Residential Recovery Counselors are scheduled on the evening and night shift seven days a week.” LPA reviewed staff schedules and timecards for the month of November 2024, which revealed that there were a total of 14 evening and night shifts in the month that only 1 Residential Counselor staff was scheduled and worked. There were an additional 7 evening and night shifts did not have any Residential Counselor staff scheduled or confirmed worked. Interview with staff and clients revealed there have been multiple occasions when there was only one staff present and working at a time at this facility. Furthermore, on the following shifts, all 4 (four) facilities on the same campus were understaffed according to the facility plan of operation: November 1 st on the evening shift there were 4 staff present in total for 4 separate licensed facilities, November 15 th on the night shift there were 4 staff present in total for 4 separate licensed facilities, November 22 nd on the night shift there were 3 staff present in total for 4 separate licensed facilities, November 23 rd on the night shift there were 3 staff present in total for 4 separate licensed facilities, November 29 th on the night shift there were 4 staff present in total for 4 separate licensed facilities, and on November 30 th on the night shift there were 3 staff present in total for 4 separate licensed facilities. Interview with staff and clients revealed there have been multiple occasions when there was only one staff present and working at a time at this facility.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted with facility and corporate management. Today’s reports and appeal rights were reviewed and provided.