Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection at the facility today and met with Administrator Judi Flickner. The purpose of today's inspection is to follow up on a self-reported incident which occurred on 08/05/2025. During today's visit there were no clients present.

On 08/05/2025, the Regional Office received an Incident Report (IR), reporting that on 08/04/2025, Client 1 (C1) was returning from a community outing arriving at the Day Program (DP) at 12 :41 p.m., clients exited the the van and the Driver 1 (D1) was back in the van to park it at 12:43 p.m. and documented the van was empty. At approximately 12:58 p.m., a staff realized C1 was not in the building and went to the van. Staff found C1 in the van "relaxed and unharmed". It was reported that the total time C1 was away from the group was apprx. 7 minutes. The driver is responsible for checking that all individuals are out of the van before locking the van. The aide, when applicable, will do a back up check to ensure that the van is empty. D1 has been terminated and the aide was suspended for the day.

The LPA reviewed previous incident reports and observed that this is the second time C1 has been left in a facility van by error. C1 was left in a facility van during a community outing on 04/21/25 for approximately 12 minutes, until staff did a count after arriving at their destination an realizing C1 was not with the group, and was discovered in their seat in the last row in the van fixated on their tablet. Driver 2 (D2) was terminated.

The following deficiencies were cited (See LIC 809-D.) from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. Report and appeal rights were provided