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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 11/28/2023
Date Signed: 11/28/2023 10:45:10 AM


Document Has Been Signed on 11/28/2023 10:45 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:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 111DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stephan McDonald TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Manager (LPM), Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility unannounced on 11/28/23 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPAs and LPM met with Executive Director (ED), Stephan McDonald and explained the purpose of the visit.

R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 10/20/23 regarding resident (R1) leaving the facility unattended on 10/12/23, at approximately 3pm. Per incident report, it was discovered R1 was missing from community on 10/12/23 around 1.30pm. Interviews indicated staff looked around for the resident but were unable to locate R1. Around 3pm, the police called the community stating they had located R1. R1 was found at their old house after R1s neighbors called the police. R1 was brought back to the facility uninjured by Executive Director, Stephan McDonald. LPA followed up with facility after this incident and gathered information for R1 including R1’s LIC602. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report, LIC602, dated 09/07/23 and R1s Needs and Service plan by facility, dated 09/23/23 indicates that resident has diagnosis of bipolar disorder and cannot leave the facility unassisted.

R1’s AWOL Incident (2)- During record review, LPA observed that R1s charting notes by facility staff indicated that R1 had another AWOL incident on 11/01/23 where R1 went to local grocery shop by themselves on 11/01/23 around 1pm. Staff did not notice R1 was missing until R1 came back to the facility. This AWOL incident was not reported to the department as required. Although the facility has implemented safety precautions for R1 after their AWOL incident on 10/12/23, those measures were not effective since R1 left again unassisted on 11/01/23 which is a safety risk for R1.

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. In addition, the facility did not report R1’s AWOL on 11/01/2023 therefore not meeting reporting requirements. 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, appeal rights has been provided to ED.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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 11/28/2023 10:45 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
CCR
87411

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by;
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Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-11/29/23.

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Based on records of the incidents for R1,
R1 AWOL from the facility on 10/12/23 and on 11/01/23. This poses a immediate risk to the health and safety of residents in care.
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Type B
12/12/2023
Section Cited
CCR87211(a)(D)

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87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by;

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Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-12/12/23.

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Based on records review,it has been observed that facility did not report R1s AWOL incident for 11/01/23 to department as required which poses potential health and safety risks for 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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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