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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200828
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:16:19 PM

Document Has Been Signed on 05/10/2024 03:16 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SWEET RIVER RESIDENTIAL CAREFACILITY NUMBER:
079200828
ADMINISTRATOR/
DIRECTOR:		MENJIVAR, RICARDO FFACILITY TYPE:
735
ADDRESS:319 ROSS AVETELEPHONE:
(925) 250-3994
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
05/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Ana Colunga, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 5/10/2024 at 2:50pm Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 5/8/2024. LPA met with Ana Colunga, Administrator and explained the purpose of the visit.

The incident occurred on 5/8/2024, early morning. S1 stated that clients were checked on at 11:00pm on 5/7/2024, during shift change by S3. S2 then checked clients at 3:00am on 5/8/2024 and observed C1 was missing. S2 checked the outside areas of the facility and did not see C1. S2 then called S1 to advise that C1 had AWOL'd. S1 called 9-1-1 and then called different hospitals. After about two (2) hours S1 found C1 at Sutter Delta Hospital. S1 stated that Antioch Police Department had found and taken C1 To Sutter Delta Hospital because officers was not able to get information from C1. C1 returned to the facility the same day.

S1 stated this is the first time C1 has AWOL'd and there is an appointment scheduled with the behaviorist on 5/15/2024, to implement a plan to deter C1 from AWOL.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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