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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002961
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:45:14 PM

Document Has Been Signed on 04/25/2022 04:45 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STANFORD HOMESFACILITY NUMBER:
306002961
ADMINISTRATOR:EUGENIO C. ABOBOFACILITY TYPE:
735
ADDRESS:440 E.WILSHIRETELEPHONE:
(714) 526-7248
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 28CENSUS: 23DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Administrator, Eugene AboboTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit on this day and arrived at 3:09 pm for the purpose of conducting a case management visit in regards to a self- reported incident received from facility on 4/18/2022. LPA was greeted and met with Administrator Eugene Abobo.

On 4/18/2022 an incident report was received regarding that on 4/17/2022 Client 1’s (C1). C1 was sitting outside with staff and Staff stepped away briefly to go back inside house, during that brief moment C1 wandered from facility unassisted. Per review of C1’s file, documents reveal C1 is able to leave facility unassisted. Physician report indicated no previous history of wandering behavior.

Staff contacted Local Police Department and Police came out to facility. After Police had arrived C1 arrived via paramedics. Staff stated that C1 claims they had a anxiety attack, went for a walk and called 911. C1 was transported to hospital for further assessment, and came back to community later that same day.

For C1's anxiety, Doctor informed Administrator to observe C1 and re-direct client when panic attack occurs. LPA observed Facility's Behavior Care Plan with C1's which was created with C1's service coordinator. Behavior care plan indicates staff will monitor C1 every 30 to 60 minutes for anxiety. Behavior Care Plan also states client should have a buddy system of another client to walk together with when leaving facility. Facility has stated they will continue to monitor Client. LPA observed client. C1 states they like being at facility and enjoys facility group walks. Client was well groomed in appearance. LPA observed other clients relaxing playing games in common areas. LPA observed No health and safety concerns during this visit.

LPA conducted exit interview with Administrator and copy of report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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