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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221317
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:20:34 PM

Document Has Been Signed on 10/12/2021 01:20 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TOMANENG GUEST HOME IFACILITY NUMBER:
191221317
ADMINISTRATOR:ESTELA TOMANENGFACILITY TYPE:
735
ADDRESS:11204 GAVIOTA ST.TELEPHONE:
(818) 831-5767
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joy Magdangal-Bonnet/ AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility administrator, Joy Magdangal-Bonnet. The administrator took the LPA's temperature upon arrival and conducted the COVID-19 questions before allowing the LPA to enter.

LPA explained that the reason for the visit was due to an incident report regarding a resident (R1) AWOL, received on 10/8/21. It was reported that R1 had eloped from R1's 1 on 1 care staff while out in the community. LPA was able to review R1's Individual Program Plan while at the home. Documents reviewed, stated that R1 is to receive 12 hours of 1 on 1 care during the day time.

The incident report indicated that R1 and R1's 1 on 1 were using the restroom when R1 left the 1 on 1 and disappeared from the outing. It was revealed that the 1 on 1 care staff is not a staff of the facility but is contracted through, Right Choice, contracted by the Regional Center.

When the facility became aware of the elopement, the facility called the police and began searching for R1. It was later determined, that R1 had gotten on a bus and traveled to a local hospital. The facility administrator was able to locate R1 and notified R1's 1 on 1 of R1's location.

R1 is currently back at the facility and no signs of injury were observed on R1.

This incident occurred while R1 was away from the facility and under the supervision of a contracted 1 on 1 who is not associated to the facility, therefore no citations were issued.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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