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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700677
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:52:50 PM

Document Has Been Signed on 10/26/2021 02:52 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MISSION HOME CBN INCFACILITY NUMBER:
342700677
ADMINISTRATOR:CENTENO, CRISELDAFACILITY TYPE:
735
ADDRESS:8591 MISSION FALLS CIRCLETELEPHONE:
(916) 519-7474
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Orlando Carpio TIME COMPLETED:
03:00 PM
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) C. Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry into the facility. Facility staff confirmed zero residents and staff have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio met with facility staff Orlando Carpio.

LPA Valerio reviewed incident reports disclosing that resident 1 (R1) physically punched two residents (R2 and R3) in the face while residing at Mission Home Care CBN, Inc. R2 and R3 are non-verbal and could not verbalize if they were in pain. R2 had a swollen face after R2 was punched by R1. R3 was not observed to have any injuries after being punched.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, a deficiency is being cited and can be found on LIC 809-D. Exit interview was held and  a copy of report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 2
Document Has Been Signed on 10/26/2021 02:52 PM - It Cannot Be Edited


Created By: Christina Valerio On 10/26/2021 at 01:29 PM
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: MISSION HOME CBN INC
FACILITY NUMBER: 342700677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited
CCR
80072(a)(3)

1
2
3
4
5
6
7
80072 Personal Rights (a)... each client shall have personal rights which include... the following: (3) To be free from...infliction of pain, humiliation,...threat, mental abuse, ...interference with the daily living functions... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee stated for any new residents referred to the home the licensee will obtain current records regarding individual program plan, LIC 602 physician report, and obtain information from previous placement. The licensee will ensure all residents are compatible with one another and free from having personal rights violated.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not ensure 2 out of 4 residents were free from infliction of pain, humiliation, threat, mental abuse, and interference with daily living functions, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee will send new resident's facility file by POC date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2