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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200927
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:03:33 PM


Document Has Been Signed on 09/06/2024 03:03 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:SMG RESIDENTIAL CARE INCFACILITY NUMBER:
079200927
ADMINISTRATOR:GONZALEZ, MARIA IFACILITY TYPE:
740
ADDRESS:2833 FORTUNA COURTTELEPHONE:
(925) 209-0791
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Gonzalez, AdministratorTIME COMPLETED:
03:10 PM
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On 09/05/2024 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/28/2024. LPA met with Administrator (ADM) and explained the purpose of the visit.

The incident report received stated that on 08/27/24 resident (R1) threatened to use stolen hospital syringes on staff due to aggressive behaviors. Staff notified police who placed him under custody due to prior arrests. When R1 came back to the facility, he requested staff to take him to the local bank and leave him there. Review of R1's physician's report show he is able to leave the facility unassisted. Since R1 did not return from the bank to the facility, administrator (ADM) filed a missing person's report with police. ADM continues to work with R1's case manager and primary care physician in addressing his needs.

ADM also issued a written 30 day notice of eviction to R1 (see attached) effective 09/30/24.

j.zier incident report 2024-08-27 s.pdfj.zier incident report 2024-08-27 s.pdf eviction notice j.zier.pdfeviction notice j.zier.pdf

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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