Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit to follow up on incident reports received at the Regional Office. Upon arrival, LPA met with staff and explained the reason for the visit. Administrator Danika-Jean Lewis arrived shortly after.

On 06/18/2025, the Regional office received an incident report that stated on 06/16/2025, Client #1 (C1) was administered incorrect medications.

On 07/10/2025, the Regional office received an incident report that stated on 07/09/2025, Client #2 (C2) struck Client #3 (C3) on top of C3's head.

On 07/13/2025, the Regional office received an incident report that stated on 07/12/2025, C2 was observed having behavior in their room, which resulted in (2) lacerations on their forehead.

On 07/16/2025, the Regional office received an incident report that stated on 07/15/2025, Client #4 (C4) missed their medication .

At approx 10:00a.m. LPA conducted physical plant, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. Interviews and records review revealed medications weren't administered as prescribed due to staff negligence.

Regarding incident on 07/09/2025 and 07/12/2025, LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). A civil penalty in the amount of $250 was issued for a repeat violation. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeals rights discussed and copy of report issued.