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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 10/19/2022
Date Signed: 10/19/2022 05:31:21 PM

Document Has Been Signed on 10/19/2022 05:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR:CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 5DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Meleani Wheeler, Supportive Living InstructorTIME COMPLETED:
05:00 PM
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On 10/19/2022 at approximately 2:45 pm, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit regarding an incident report submitted on 09/29/22. LPA met with Supportive Living Instructor (SLI) Meleani Wheeler and explained the purpose of the visit. After contacting the Director, for permission to assist and sign licensing documents, SIL provided the necessary documents regarding the incident.

Though an incident report was submitted, it was not reported that R1's brother was contacted. LPA suggested SLI call brother to confirm he knew about it. LPA observed that the brother was listed as R1's emergency contact with his phone number. LPA saw SLI make call on speaker phone and LPA spoke to the brother. He confirmed he was notified of R1's accident.

LPA interviewed Staff (S1) regarding the incident that occurred on 09/29/22 at 6:20 am. S1 explained he heard a scream and came in to find R1 on the floor naked at the foot of her bed.Staff (S2) came in and called 911.

S1 stated that R1 has no significant history of falling, while living at the facility but she could be unsteady on her feet. R1 uses a walker and is monitored during showers, without hands-on support. She can dress herself and get to the bus with little assistance. LPA conducted additional interviews with residents who were present in the facility at the time of the incident.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Supportive Living Instructor, Meleanie Wheeler.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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