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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700065
Report Date: 06/23/2023
Date Signed: 06/23/2023 11:49:39 AM

Document Has Been Signed on 06/23/2023 11:49 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WILTON STABLESFACILITY NUMBER:
342700065
ADMINISTRATOR:TANYA BARRETOFACILITY TYPE:
735
ADDRESS:11119 MANN ROADTELEPHONE:
(916) 687-4548
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY: 4CENSUS: DATE:
06/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tanya BarretoTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA arrived and no one answered the door. LPA called the facility two times, called the administrator, and texted the administrator. Administrator replied that staff are with the resident at work and other residents are in day program. LPA spoke to administrator via phone and explained the purpose of the visit. Administrator stated staff or residents would not be at the facility until 4:00 PM. LPA held visit over phone and requested Administrator sign the documents and send to LPA.

LPA received notification of an incident involving Resident 1 (R1). On 04/21/2023, R1 was dropped off at family home by facility staff. Later in the afternoon, the family reported that R1 assaulted a family member resulting in the family calling the facility to come pick R1 up. Administrator Tanya informed the family there is no staff available and R1 would not be picked up until the next day on 04/22/2023. Based on an interview, this is not the first time the facility denied to pick up R1 after having an assaultive behavioral outburst. According to a Facility Action Report dated May 4th, 2023, the facility violated Title 17 56054(a)(4) due to failure to provide consumer services as specified in the consumer's IPP.

According to the Program Design, Wilton Stables will provide transportation services for all residents in the facility vehicle. Wilton Stables will provide transportation services as needed to and from all medical and dental appointments as well as all community outings.

LPA reviewed electronic files and did not receive an Unusual Incident Report for R1's visit nor was the information relayed verbally to LPA. LPA requested personnel files with driver's license and copies of staff schedules.
Per California Code of Regulations, Title 22, deficiencies are being cited and can be found on the LIC 809-D page. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a report was provided via email. No questions were mentioned, administrator confirmed verbally of information being discussed.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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 06/23/2023 11:49 AM - It Cannot Be Edited


Created By: Christina Valerio On 06/23/2023 at 09:43 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WILTON STABLES
FACILITY NUMBER: 342700065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated they have met with Alta Regional Center to discuss R1's home visitations, develop a plan to ensure staff are able to pick up R1 in a reasonable timeframe, and to set up a staffing schedule that will allow for staff to pick up residents. LPA to receive copies of information by POC due date.
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Based on records review and interviews, the licensee did not ensure R1 was provided care or supervison as necessary to meet the client's needs. This poses a potential health, safety, and personal rights risk to residents in care.
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Type B
07/21/2023
Section Cited
CCR80061(b)

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80061 Reporting Requirements (b)Upon the occurrence, ..., a report shall be made to the licensing agency within the agency's next working day... In addition, a written report... shall be submitted to the licensing agency within seven days...This requirement was not met as evidenced by:
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Licensee stated administrator and staff will review Title 80061 and write a statement of acknowledgment stating they understand the regulation and their plan to meet standards moving forward. This statement and in-service sign in sheet will be sent to LPA by POC due date.
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Based on file review, the licensee did not ensure incident were reported to the regional office, which poses a potential health and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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