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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200342
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:27:39 PM

Document Has Been Signed on 12/04/2023 01:27 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REGINA HAVENFACILITY NUMBER:
079200342
ADMINISTRATOR:MELISSA LIPARDOFACILITY TYPE:
735
ADDRESS:4621 REGINA LANETELEPHONE:
(650) 483-7269
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
12/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bernadette Lee, AdministratorTIME COMPLETED:
01:45 PM
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On 12/04/2023, 12:45 PM, Licensing Program Analyst (LPA) P. Watson unannounced to conduct a case management visit to discuss the usage of restraints for C1. LPA met with Administrator, Bernadette Lee, and explained the purpose of the visit.

Administrator stated that they were unaware that the harness was being used, and stored at the facility, the harness has been used since before they became the Administrator. Administrator became aware of the usage after C1's Behaviorist brought it to their attention. Administrator stated that C1's day program has a doctor note stating why C1 needs to use the restraint during transportation but have not observed those doctors note. While C1 is being transported by facility staff for outing C1 does not wear a harness nor hand restraints and uses a regular seat belt with no issues.

LPA asked what procedures do facility have in place when C1 has behaviors, Administrator stated that they remove C1 from their housemates, allow him to calm down and give him milk and/or snacks to help C1 from bitting themselves. Staff (S1), stated that they also redirect C1 when they are actively bitting themselves. Staff have CPI training. C1 is not a harm to housemates or staff.

LPA was informed that since Administrator became aware of the harness it has no longer been used and facility has gotten rid of it. A clinical team meeting with Regional Center is scheduled for next month to discuss this issue further.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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