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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701155
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:26:12 PM

Document Has Been Signed on 01/14/2025 12:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MILESTONE CAREHOME INCFACILITY NUMBER:
342701155
ADMINISTRATOR/
DIRECTOR:		MERCADO, JENNIFERFACILITY TYPE:
735
ADDRESS:9001 GENERATIONS DRTELEPHONE:
(916) 478-0478
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jennifer MercadoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Jennifer Mercado and explained the purpose of the visit.

LPA Moleski received an incident report from Mercado on 1/12/25. The incident report indicated that a resident (R1) was out shopping with two staff members (S1-S2) on that same date, but, while waiting in line to pay, R1 "seemed to have seen someone," and started running around. S1 attempted to redirect R1, but R1 ran out of the store.

S1 attempted to follow R1, but R1 outran S1, according to the incident report. S1 then called 911, and 30 minutes later a local police officer arrived at the facility with R1, according to the incident report. R1 had been found by police while walking unaccompanied in the community, and agreed to have officers drive R1 back to the facility.

In an interview, Mercado said that S1 was responsible for supervising R1 on the outing, as S2 was supervising another client accompanying them. LPA Moleski asked what preventative measures are in place on outings to prevent R1 from eloping. Mercado said "[R1] doesn't have anything in place" because the incident previously described was the first incident of elopement while on an outing.

In a phone interview, S1 said that R1 got agitated, and was either bored while waiting in line at the store, or possibly saw someone that they were scared of. S1 said that R1 had previously stolen from the store, and may have been agitated if they saw the manager. Mercado confirmed the previous incident of theft from the store, and said R1 will not be returning to that store in the future. LPA Moleski asked S1 if there is a plan in place to prevent R1 from eloping while on outings. S1 said that staff "give [R1] what [R1] wants" or "tell [R1] what [R1] wants to hear" in order to soothe R1, such as promising a preferred snack or activity. [continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 01/14/2025 12:26 PM - It Cannot Be Edited


Created By: Vincent Moleski On 01/14/2025 at 11:28 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
80078(a)

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"(a) The licensee shall provide care and supervision as necessary to meet the client's needs." This requirement was not met as evidenced by:
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Licensee agrees to provide a written plan of correction by POC due date after discussing the incident with R1's behaviorist.
vincent.moleski@dss.ca.gov
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Based on interview and record review, R1 was not provided the necessary care and supervision to prevent elopement, nor was R1 provided the necessary care and supervision while out in the community unsupervised, which poses an immediate health, safety, and/or personal rights risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155
VISIT DATE: 01/14/2025
NARRATIVE
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LPA Moleski reviewed R1's file. R1's LIC 602, dated 12/2/22, indicates that R1 is not allowed to leave the facility unassisted. Additionally, R1's IPP, dated 10/20/23, indicates that R1 has a history of elopements. R1's behavior intervention plan, dated 10/25/23, also indicates that R1 has a history of elopements. The behavior intervention plan describes R1's behavioral antecedents to episodes of elopement, including being in a public place, and furthermore states that staff "should keep [R1] within line of sight during all waking hours," and that "in community locations, particularly if waiting, staff will provide [R1] with tasks to complete and/or items to focus on."

This facility is hereby cited per 22 CCR Section 80078(a). An exit interview was held with Mercado. Appeal rights and a copy of this report were left with Mercado.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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