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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004442
Report Date: 02/08/2023
Date Signed: 02/09/2023 07:00:34 AM

Document Has Been Signed on 02/09/2023 07:00 AM - 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:D & D HOMESFACILITY NUMBER:
306004442
ADMINISTRATOR:DIZON, DEXTER R.FACILITY TYPE:
735
ADDRESS:1922 E.WILLOW STREETTELEPHONE:
(714) 860-4445
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 6DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Eduardo ManikadTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit to follow up on incident report submitted to Community Care Licensing on 01/30/2023. LPA was greeted and granted entry into the facility by Care Staff Pedro Canoza and explained the reason for the visit. Administrator Dizon Dexter and House Manager Eduardo Manikad arrived shortly after.

Incident report dated 01/30/2022 indicated that at 8:00am Staff 1 (S1) was preparing the Client 1's (C1) glucometer to check blood sugar when staff notices C1 was not in bed. Staff reported to Administrator and drove around looking for C1 at nearby stores and restaurants. Administrator instructed staff at noon to file Report with the Anaheim Police Department. At 4:15 PM Anaheim Police Officer showed up to the facility and took a report. On 01/30/2023, S1 received a call at noon from Garden Grove Police Department notifying that C1 was found and C1 will be dropped off at the facility.

LPA interviewed Staff 2 (S2) and Staff 3 (S3) who are live-in staff who stated C1 leaves or attempts to leave the facility about once or so a month and is found at nearby restaurants or a store when C1 has left. LPA reviewed C1's file; per Physician's Report dated 7/13/2020, C1 is able to leave facility unassisted. In reviewing C1's Individual Program Plan (IPP) dated 4/19/2022, states C1 "requires 24/7 supervision".

LPA Martinez received a copy of C1's Annual Behavior Date Summary which shows C1 had 30 incidents of Eloping from January 2022 to December 2022. From January 2023 to present, C1 has had 4 incidents of Eloping. None have been reported to CCL but one (1/29/2023) incident.

Based on the observations and interviews made, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report will be emailed
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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 02/09/2023 07:00 AM - It Cannot Be Edited


Created By: Lydia Martinez On 02/08/2023 at 11:47 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: D & D HOMES
FACILITY NUMBER: 306004442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
80061(a)(1)(E)

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Reporting Requirements indicates that: "(a) Each licensee or applicant shall furnish to the licensing agency reports (...), including (...) (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client."
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Administrator to review the cited regulation and ensure that an adequate reporting process is in place for any future incidents.
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This requirement was not met as evidenced by 30 unreported incidents in 2022 of C1 Elopeing. This failure to report poses a potential risk to the health and safety of the clients in charge.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023


LIC809 (FAS) - (06/04)
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