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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602405
Report Date: 05/12/2022
Date Signed: 05/17/2022 01:48:26 PM

Document Has Been Signed on 05/17/2022 01:48 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANEW DIRECTION ADULT LIVINGFACILITY NUMBER:
198602405
ADMINISTRATOR:PATRICIA DUFRENNEFACILITY TYPE:
735
ADDRESS:2300 S PACIFIC AVETELEPHONE:
(909) 210-0365
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY: 72CENSUS: 58DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kenneth Beck, House ManagerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Ana Soto initiated a case management visit to the facility listed above. Today’s case management was conducted with Kenneth Beck, House Manager.

The facility submitted an SIR dated 05/02/22 to CCLD. Reporting that C1 set C1-self on fire. He was in the patio area, was seen with a playing with a lighter. C1 put the lighter in his shirt pocket and began to have a seizure. C1 shirt caught on fire and burned on C1 chest and left hip. C1 received 2 degree burns and was taken to the Harbor UCLA Hopsital burn unit. On 05/02/22, LPA interviewed Administrator. On 05/12/22, LPA interviewed house manager and Assistant Administrator. C1 still remains in the hospital and doing good. C1 will return to facility was cleared by physician. C1 belongs to the Tele-care program and they will be relocating C1 to a facility with a higher level of care. C1 will not be returning to facility.

An exit interview was conducted with Kenneth Beck, House Manager and a copy of report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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