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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201099
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:17:21 PM

Document Has Been Signed on 08/25/2023 03:17 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:GARCIA'S PLACE, INC.FACILITY NUMBER:
079201099
ADMINISTRATOR:OVILIO BARRIOS GARCIAFACILITY TYPE:
735
ADDRESS:1712 SAN JOSE DRIVETELEPHONE:
(925) 565-5731
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
08/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Ovilio Barrios Garcia, AdministratorTIME COMPLETED:
03:25 PM
NARRATIVE
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On 8/25/2023 at 02:25pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit. This a follow-up visit pertaining to a questionable death of a client who passed away on 10/08/2022. On 10/08/2022, Client 1 (C1) eloped from the facility. Staff failed to adequately supervise C1, leading to him being shot in the community which caused his death. LPA met with Ovilio Barrios Garcia, Administrator and explained the reason for the visit.

The Department’s investigation included but was not limited to interviews with current staff, witnesses, clients, and the collection and review of records from the facility and Antioch Police Department (APD).

Client 1 (C1) was admitted to the facility on 8/21/2022. It was noted on C1’s post placement Individual Service Plan (ISP), dated 8/18/2022, that C1 was an elopement risk, and exhibited verbal and physical aggression behaviors. The facility requested C1 to have a 1:1 staff. The Department received confirmation from the Regional Center of the East Bay (RCEB) that approval was given for the 1:1 effective 8/21/2022 to 2/28/2023. During record review the Department reviewed incident report dated 09/19/2022 which indicates C1 eloped, but staff was able to follow C1. The incident report dated 09/27/2022 indicates C1 eloped from the facility without staff knowledge.

Based on interviews and documentation, C1 had a history of failing to follow staff orders or house rules. Staff stated C1 would often become angry and verbally aggressive towards staff if they tried to implement the rules. C1 also had a history of leaving the facility without permission and without supervision by leaving through his bedroom

Continued on LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GARCIA'S PLACE, INC.
FACILITY NUMBER: 079201099
VISIT DATE: 08/25/2023
NARRATIVE
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Continued from LIC809.

window. C1s’ care plan was not updated to mitigate him from leaving the facility unsupervised. It also indicated C1 left the facility unsupervised early in the morning 10/08/2022 stating he was going to “work.” C1 returned home at approximately 11:30pm, went to his room, locked the door, and played loud music. At 11:40pm, staff knocked on the door, however, did not receive a response and figured C1 was asleep. At approximately 03:00am, Antioch Police Department called and informed the Licensee that C1 had been shot and killed in the community. Facility staff then checked on C1 and realized that C1 had eloped from his window which was observed to be open.

According to APD records, C1 was a suspect and involved in an attempted home invasion which resulted in C1 being shot.

Deficiencies are cited under the California Code of Regulations, Title 22, Division 6, follows on LIC809D.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to death of client is pending.

A Non-Compliance Conference (NCC) will be scheduled for a later date.

Exit interview conducted. A copy of the LIC421M, appeal Rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2023 03:17 PM - It Cannot Be Edited


Created By: Laura Hall On 08/25/2023 at 02:46 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GARCIA'S PLACE, INC.
FACILITY NUMBER: 079201099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2023
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidence by:
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The Licensee will submit a written plan of correction to CCL indicating the prevention of this in the future. A mandatory meeting will be scheduled at a later date.
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Based on observation the Licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care.
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A Non-Compliance Conference (NCC) will be scheduled.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to death of a client is pending.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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