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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006074
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:11:01 PM

Document Has Been Signed on 01/13/2023 03:11 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:SUCCESSFUL PEOPLE LLC #5FACILITY NUMBER:
306006074
ADMINISTRATOR:SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1774 W CHALET AVETELEPHONE:
(310) 902-4893
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Cyhante BrewsterTIME COMPLETED:
03:25 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 01/09/23 regarding an elopement involving Resident #1 (R1). LPA met with Staff #1 (S1) Cyhante Brewster and discussed the purpose of the inspection. Administrator (AD) Frances Snoddy appeared via telephone.
The incident report states that on 01/08/23, R1 became agitated, stated they were leaving and started packing their clothes and belongings, staff attempted to redirect R1 and asked R1 to sign out but R1 refused, R1 left the facility, facility staff attempted to call R1 multiple times with no answer, facility staff called 911 and R1’s family, and facility staff were advised by R1’s family that R1 had been admitted into a psychiatric hospital.

During today’s inspection, LPA conducted a health and safety check on R1, observed no health and safety issues, and observed R1 was in good health and good spirits. LPA reviewed R1’s Individual Program Plan which states that R1 has a history of elopement. LPA reviewed R1’s Physician Report which states that R1 is not able to leave the facility unassisted. LPA interviewed S1 who provided the following information: this is R1’s second elopement while at the facility; when R1 walked out, facility staff followed R1 to the sidewalk, noted R1’s clothing and direction, but was not able to continue to follow R1; facility staff notified the police and R1’s family; the police advised that R1 is able to leave but took the information for a possible 5150; R1 ended up at psychiatric hospital; and R1 returned to the facility the next day on 01/09/23. S1 stated that the facility has an elopement protocol and it was followed during this incident. LPA provided technical assistance regarding elopement and eviction.

Based on the information obtained during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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