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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204067
Report Date: 10/16/2024
Date Signed: 10/18/2024 01:36:16 PM

Document Has Been Signed on 10/18/2024 01:36 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:POSITIVE SUPPORTSFACILITY NUMBER:
157204067
ADMINISTRATOR/
DIRECTOR:		MATA, DEBBIEFACILITY TYPE:
775
ADDRESS:618 MAIN STREETTELEPHONE:
(661) 721-3236
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 75CENSUS: 29DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Debbie Mata, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 10/16/24, Licensing Program Analysts (LPAs) L. Salazar and M. Medina arrived at the facility unannounced to conduct a case management visit based on a self reported incident. LPA met with Administrator/Program Director to discuss.

On 08/12/24 @ 12:10PM, Client C1 was observed having lunch on the outside patio. At 12:20PM Staff S1 went to check on C1 and notices they were gone. The facility was searched inside and out and C1 was not there. Day program called the facility administrator where C1 resides and 911. Day Program staff drove in town and observed C1 @12:40 to be approximately 2 blocks away on a main road. C1 refused to get in the car with staff. Administrator arrived to the day program and drove to pick up C1 and take them home. C1 reported they were fine. No injuries noted.

LPA observed C1's LIC 602 (Physician's report) dated 01/25/24 and Individuals Performance Plan (IPP) / Needs and Service appraisal dated 05/22/24. LIC 602 indicates C1 cannot leave the facility unattended. IPP does not state anything about history of elopement, attempted elopement or need for 1:1 staffing.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D. A immediate civil penalty is being assessed in the amount of $500 for care and supervision, if not corrected the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

An exit interview was conducted with Program Director (PD). PD stated a plan of correction was developed with Central Valley Regional Center (CVRC) that C1 would have 1:1 supervision during the lunch hour for 30 days. LPA did not observe any documentation of this. PD will contact CVRC to ensure IPP is accurate and reflects that C1 is known to elope. A copy of this report and appeal rights were provided via email with a read receipt as proof of delivery.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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Document Has Been Signed on 10/18/2024 01:36 PM - It Cannot Be Edited


Created By: Lisa Salazar On 10/16/2024 at 05:06 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: POSITIVE SUPPORTS
FACILITY NUMBER: 157204067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
CCR
82065(e)

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Personnel Requirements
82065 (e)
The licensee shall provide for direct supervision of clients during participation in or presence at potentially dangerous activities or areas in the day program. This requirement was not met as evidenced by LPAs observation of self reported incident and interview with Program Director stating Client C1 eloped from the day program for approximately 20 minutes on a busy main street.
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Program Director (PD) met with CVRC and was provided 1 on 1 supervision for C1 during lunch hour for 30 days. No attempted elopements since. PD will ensure IPP is updated at quarterly meeting in Novemver 2024.
POC CLEARED

**An immediate $500 Civil Penaltywas hereby assessed**
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A immediate civil penalty is being assessed in the amount of $500 for care and supervision, if not corrected the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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