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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700945
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:33:25 PM

Document Has Been Signed on 08/08/2023 04:33 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:WELLCARE HOMES 3FACILITY NUMBER:
342700945
ADMINISTRATOR:CAMALIG, YVONNE K.FACILITY TYPE:
737
ADDRESS:10799 SIMMERHORN RD.TELEPHONE:
(916) 639-0091
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: DATE:
08/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yvonne CamaligTIME COMPLETED:
04:45 PM
NARRATIVE
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On 8/8/23 at approximately 2:30pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management. LPAs Jensen and Fain met with Administrator Yvonne Camalig and explained the purpose of today's visit.

On 1-19-23, the Department of Developmental Services (DDS) arrived at facility and conducted a semi-annual review. During the course of the semi-annual review on 1/19/23, DDS determined that personnel qualification and training requirements were not met. In addition staffing ratios were not met on December 14, 2022 and December 16, 2022.

Personnel Qualification and Training Requirements

The California Code of Regulations (CCR) requires Enhanced Behavioral Support Homes ensure that each direct care staff person has six months prior experience providing direct care to individuals with developmental disabilities; and becomes a Registered Behavior Technician within twelve (12) months of initial employment. The facility employees 3 direct care staff personnel who have been employed over 12 months and 2 of the 3 direct care staff with this length of tenure have not received their Registered Behavior Technician certification.

The California Code of Regulations (CCR) also requires Enhanced Behavioral Support Homes ensure that each direct care lead staff person has one year prior experience providing direct care to individuals with developmental disabilities; and becomes a Registered Behavior Technician within six (6) months of initial employment or is a Licensed Psychiatric Technician or Qualified Behavior Modification Professional . The facility employees 5 direct care lead staff personnel of which 4 were Registered Behavior Technicians at the time of the semi-annual review. The direct care lead staff person that lacked the certification as a Registered Behavior Technician has ceased employment with the facility.

Continued on LIC 809C...


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WELLCARE HOMES 3
FACILITY NUMBER: 342700945
VISIT DATE: 08/08/2023
NARRATIVE
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Continued from LIC 809...
Staffing Ratios
The CCR requires Enhanced Behavioral Support Homes to ensure that there is at least one direct care lead staff person on duty at all times when a client is under the supervision of the facility staff. Based on staffing schedules reviewed during the course of the semi-annual review conducted on 1/19/23 there was not a lead staff on duty during the AM shift of 12/14/22 and 12/16/22.

Deficiencies are being cited from CCR, Title 22, Division 6. Failure to correct deficiencies may result ion the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
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Document Has Been Signed on 08/08/2023 04:33 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/08/2023 at 04:01 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: WELLCARE HOMES 3
FACILITY NUMBER: 342700945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
CCR
89965(a)-(c)

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Personnel Requirements
(a) The licensee shall ensure that each direct care lead staff person meets the following qualifications:

(1) Have one year prior experience providing direct care to individuals with developmental disabilities; and be one of the following:

(A) Become a Registered Behavior Technician within six months of initial employment, or

(B) Be a licensed psychiatric technician, or

(C) Be a Qualified Behavior Modification Professional.

(b) The licensee shall ensure that each direct care staff person meets the following qualifications:

(1) Have six months prior experience providing direct care to individuals with developmental disabilities; and

(2) Become a Registered Behavior Technician within twelve (12) months of initial employment.

(c) There shall be one direct care lead staff person and one direct care staff person on duty at all times when a client is under the supervision of the facility staff. This requirement was not as evidenced by:
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The Licensee has implemented a new process wherein they are tracking training requirements and the staff members progress towards the completion of obtaining the certifications required. In addition the facility is adding the Administrator and house manager to all schedules as a default lead in the event that a lead staff person calls off on a shift. The Licensee agrees to submit the revised schedule to jennifer.faindss.ca.gov by the POC due date.
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Based on record reviews indicating 3 facility staff did not have the required qualifications for their position and 2 dates in December when there was no lead staff on duty. This poses a potential risk to the heath, safety and personal rights of 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


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Document Has Been Signed on 08/08/2023 04:33 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/08/2023 at 04:14 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: WELLCARE HOMES 3
FACILITY NUMBER: 342700945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
CCR
80064(a)(3)

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Administrator Qualifications and duties
The administrator shall have the following qualifications:...
Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:

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The Licensee agrees email a signed attestation the this regulation has been read, understood and will be complied with to jennifer.fain@dss.ca.gov by the POC due date.
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Based on facility schedules reviewed by DDS the facility did not have a direct care staff lead on 2 occassions in December of 2022.
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


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