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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001341
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:38:50 AM

Document Has Been Signed on 08/17/2023 10:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRIDLEY ADULT SERVICES PROGRAMFACILITY NUMBER:
045001341
ADMINISTRATOR:CHERYL CHILDERSFACILITY TYPE:
775
ADDRESS:262 LITTLE AVENUETELEPHONE:
(530) 846-4988
CITY:GRIDLEYSTATE: CAZIP CODE:
95948
CAPACITY: 25CENSUS: 22DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cheryl ChildersTIME COMPLETED:
10:45 AM
NARRATIVE
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LPA conducted this visit as a result of a complaint visit. The facility had a client who had behaviors the facility staff were not trained to de-escalate the behaviors.

This citation is issued because the staff were not trained to properly de-escalate the behaviors.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left

Appeal rights were issued.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/17/2023 10:38 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 08/17/2023 at 10:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRIDLEY ADULT SERVICES PROGRAM
FACILITY NUMBER: 045001341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2023
Section Cited
CCR
82065(f)

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Personnel Requirements. All personnel shall be given on-the-job training or shall have related experience providing knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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By 09/17/2023, the licensee shall submit how staff shall have training addressing different types of behaviors and how to de-escalate situations.
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This requirement is not met as evidenced by: Based on LPA's interviews the staff were not properly trained to handle a client's behavior. This does not pose an immediate risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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