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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700184
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:47:49 AM


Document Has Been Signed on 10/19/2022 10:47 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SHEARWATER RESIDENCEFACILITY NUMBER:
342700184
ADMINISTRATOR:THOMAS, REBECCAFACILITY TYPE:
740
ADDRESS:6526 MAIN AVETELEPHONE:
(916) 989-1060
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:16CENSUS: 15DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rebecca ThomasTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/19/22 to conduct a case management to follow up on a recent AWOL at the facility. LPM and LPA met with facility Administrator Rebecca Thomas and explained the purpose of the visit. LPM and LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical masks. LPM and LPA were screened upon entry by staff.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 09/27/2022 regarding resident (R1) leaving the facility unattended on 09/22/22, at approximately 8:45 pm. Facility staff (S1) found R1 missing from facility while doing facility rounds on 09/22/22 around 8:45pm. S1 searched entire facility including backyard but did not locate R1 and notified administrator and sheriff. Facility staff and sheriff did through search in the area to look for R1 and sheriff found R1 sitting at neighbor house. 9-1-1 was called after R1 was found and R1 was transferred to local Hospital for further evaluation. R1 was evaluated in ER and treated for scrap on R1s right knee. R1 returned from hospital on the same day.

R1's physician's report, dated 06/01/22, indicates that resident has diagnosis of parkinson’s (primary) and dementia (secondary) and cannot leave the facility unassisted. This was first AWOL incident for R1 since admission to the facility. R1 has been discharged to another facility for higher level of care.

Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D.
Exit interview conducted. Copy of report and appeal rights provided to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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Document Has Been Signed on 10/19/2022 10:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: SHEARWATER RESIDENCE
FACILITY NUMBER: 342700184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2022
Section Cited

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87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Based on interviews conducted and record review, facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted which posed an immediate 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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