Facility Evaluation Report

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM. Entrance interview conducted.

LPA along with Donald tour the facility inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 regulations.

Upon tour at 11:15 a.m., LPA counted seven (7) resident in the facility, five (5) where in the dining room, one (1) was in the living room watching television, 1 was in their room. LPA questioned Donald regarding extra resident. Donald stated that resident is staying in Bedroom #2 with another resident. LPA observed the facility sketch and fire clearance and noticed Bedroom #2 is cleared to have only 1 occupancy. Interview with resident #7 (R7) 12:00 p.m. revealed that they are staying with another resident in bedroom number #2.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of

Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in

Civil penalties will be assessed against any facility that fails to take corrective action within described time

periods. The facility is hereby notified that a civil penalty will be assessed beginning on 11/5/2021. An Immediate Civil Penalty Assessment of $500.00 has been issued today 11/5/2021 for Fire Clearance.

Exit interview conducted. A copy of the report and appeal rights were provided via email to admin.