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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004560
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:08:15 AM

Document Has Been Signed on 01/19/2024 11:08 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REACH ADULT DEVELOPMENT SITE #5FACILITY NUMBER:
317004560
ADMINISTRATOR:SUH, SEANFACILITY TYPE:
775
ADDRESS:9980 NIBLICK DRTELEPHONE:
(916) 778-8696
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 45CENSUS: 18DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Orlando AreizagaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced case management visit on 1/19/24. This visit is to follow-up on an incident report received on 1/11/24. LPA met with the Program Director.

The incident report submitted on 1/11/24 involving an aggressive act by R1 toward R2 on 1/10/24. In response to the incident report, LPA requested and received copies of additional incidents involving R1 on prior dates of 11/22/23 and 11/24/23 aggression toward R3 and an incident on 1/4/24 toward R2.

R1 is currently "suspended" from the program and will return 1/24/24.

In all incidents, R1 did not appear to demonstrate overt indicators prior to targeting others. Appropriate staffing was in place. R2 and R3 did not suffer significant injuries.

Licensee had an emergency planning meeting regarding R1. Strategies, staffing and training has taken place to increase to chance for R1 to be successful and for other clients to be safe from harm.

No deficiencies are cited as a result of this visit.

Exit interview conducted, a copy of this report provided on this date.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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