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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006074
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:03:16 PM

Document Has Been Signed on 05/23/2024 04:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUCCESSFUL PEOPLE LLC #5FACILITY NUMBER:
306006074
ADMINISTRATOR/
DIRECTOR:		SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1774 W CHALET AVETELEPHONE:
(310) 902-4893
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 3DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Adrianna Harbin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident report submitted to the department on May 8, 2024 by facility administrator. LPA was greeted and granted entry into the facility by Marcus Fuller, Direct Support Professional (DSP II) and explained the reason for the visit.

The purpose of this visit is for a case management incident where a client eloped from the facility. LPA requested staff and resident files and interviewed client (C1), staff (S1) and Adrianna Harbin, Administrator (AD).

S1 arrived at noon for his shift. C1 was on the phone with his grandmother and was clenching his fist. Client was told by grandmother he had received money. S1 was asked to speak with grandmother regarding the funds and it was unclear if the daughter had sent it. C1 ended the phone call and perseverated over the money not received.



Client has a history of Absent Without Leave (AWOL) from facilities in his medical assessment from Regional Center. He is not allowed to leave unassisted. On the date of the incident The AD, S1 and a second staff member were all present and there were three clients residing at the facility.

While S1 prepared dinner, C1 exited through the front door without shoes on. S1 immediately ran outside to visually check which direction C1 was heading. At that time the AD and second staff member were at the local grocery store purchasing supplies. Within minutes they arrived and AD called Anaheim Police Department (PD) to file a missing person report. PD Report # 24-70434 by Officer Wiseman. S1 loaded the two remaining clients in the van and drove the local neighborhood. The police found the client on Euclid Avenue and brought him to the hospital to be evaluated. They were able to reunite client with his facility based on the police report filed by AD. Upon interview of C1 he does not remember the incident and stated he is fine. AD always has three staff in the afternoon and C1 is always partnered with a staff member since the incident.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUCCESSFUL PEOPLE LLC #5
FACILITY NUMBER: 306006074
VISIT DATE: 05/23/2024
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Based on LPA observations and interviews there was adequate staffing and the agitated, exit seeking client saw an opportunity to leave while S1 was preparing dinner. After the incident the AD will leave two staff members in facility or take C1 with staff while doing errands.

An exit interview was conducted with AD Adrianna Harbin and a copy of this report was provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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