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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800469
Report Date: 04/04/2022
Date Signed: 04/04/2022 03:08:27 PM

Document Has Been Signed on 04/04/2022 03:08 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:RAPHA HOUSEFACILITY NUMBER:
331800469
ADMINISTRATOR:KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:13310 OCOTILLO ROADTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY: 4CENSUS: 2DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Raven JohnsonTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/04/2022 at 01:18 PM, unannounced in order to conduct a case management visit. This case management visit was made regarding an incident that occurred at the facility on an allegation of sexual assault that was submitted to Community Care Licensing (CCL) on 04/01/2022. The incident was self-reported by the facility, and therefore investigated as a Case Management Incident and not as a complaint. LPA Brown met with careviger Raven Johnson and advised her of the purpose of today's visit. House Manager Eumika Foster was contacted and informed of the visit. Below is a summary of the investigation findings:

Through an investigation done by this Department, it was found that Resident 1 (R1) sneaked a female individual into R1’s room through the sliding glass door which is not far from the facility’s side gate. It was reported that the female fought R1 and stabbed R1 because R1 was being rough at female that was sneaked in and then the female called the police then the police arrived. Additionally, medical attention was sought for R1's injury. Based on records review and interviews, Staff 1 completed the scheduled resident check at 7:00 PM which the facility do every two (2) hours. Lastly, Daily Log notes from the facility for the date of the incident indicated that R1 was in his room, alone, and everything is ok from the hours of 07:00 PM to 07:59 PM until the incident occurred at 8:00 PM.

LPA Brown contacted House Manager Uumika Foster and she stated that they will put a lock on R1’s bedroom sliding door not later than 04/11/2022 to make sure this incident will not happen again .

Due to lack of evidence suggesting lack of supervision resulted to sexual assault occurred at the facility, the investigation finds the allegation UNSUBSTANTIATED.

LPA Brown conducted an exit interview with caregiver Raven Johnson, and this report (LIC809) was discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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