<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700184
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:12:06 AM


Document Has Been Signed on 10/02/2024 11:12 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:SHEARWATER RESIDENCEFACILITY NUMBER:
342700184
ADMINISTRATOR:THOMAS, REBECCAFACILITY TYPE:
740
ADDRESS:6526 MAIN AVETELEPHONE:
(916) 989-1060
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:16CENSUS: 13DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Rebecca ThomasTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/02/24 to do case management visit . LPA met with administrator Rebecca Thomas (Becky) and explained the purpose of the visit.

Department followed up on Incident Report and SOC 341 sent by facility on 09/30/24 stating that resident, R1 reported to staff on 09/20/24 that staff, S1 yelled at R1 while providing care to R1 during routine care on 09/19/24 around 10AM . Facility notified R1s family, Adult Protective Services, Long Term Care Ombudsman and other required agencies regarding this incident on 09/30/24. Per facility’s records, R1 was doing fine after this incident. LPA was notified by administrator that facility took appropriate action with S1 regarding this incident per facility policy.

During today’s visit, the Department conducted interviews with resident, R1 and staff ,S1 regarding this incident.

At this time, this case in under review and department will do follow up as warranted.

No citations were issued per Title 22 Regulations.
Exit interview conducted and copy of the report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1