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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208854
Report Date: 11/03/2021
Date Signed: 11/03/2021 08:16:34 PM

Document Has Been Signed on 11/03/2021 08:16 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HOUGHTON HOMEFACILITY NUMBER:
157208854
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:6444 HOUGHTON RDTELEPHONE:
(661) 827-8025
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 4CENSUS: 3DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:15 PM
MET WITH:Administrator Shannon SaysonTIME COMPLETED:
08:30 PM
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A Case Management visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Administrator (Admin) Shannon Sayson. The purpose of this visit is to review recent incidents regarding client altercation. Facility self- reported incidents.

On 10/22/21 Client 1 (C1) & Client 2 (C2) were involved in a physical altercation that resulted in a fractured nose for C1. Facility staff intervened immediately, redirected C1 & C2 & sought immediate medical attention by calling 911. C1 was diagnosed at hospital with nasal fracture & released back to facility with instructions to follow-up with physician. Facility staff increase observation of clients.

On 10/28/21 a 2nd altercation occurred between C1 & C2. C1 sent to hospital & released same day with no additional injuries Facility has increased monitoring & distance C1 & C2 from each other as possible. Facility is working with physicians & C1 is in process of being reassessed in order to meet C1's current needs.. Both incidents were spontaneous with no predictable indications prior to occurrence. Facility followed & continues to follow facility policies & procedures.

No deficiencies issued. Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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