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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701204
Report Date: 01/22/2024
Date Signed: 01/22/2024 11:48:25 AM

Document Has Been Signed on 01/22/2024 11:48 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTHSTAR CAREHOMEFACILITY NUMBER:
342701204
ADMINISTRATOR:ABENGANA, JERRY Y.FACILITY TYPE:
735
ADDRESS:3469 DURELLO CIRCLETELEPHONE:
(909) 525-8758
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 3DATE:
01/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Elaine AbenganaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA was met by facility staff Rose Britcher, and explained the purpose of the visit. LPA was later met by designated staff Elaine Abengana.

The Regional Office received notification that the Facility Administrator would like to bring Staff 1 (S1) back to the facility after being put on administrative leave. Due to the assigned LPA being out, LPA Valerio will be following up on the incident of suspected abuse.

On 12/15/2023, an Special Incident Report (SIR) was submitted by Alta California Regional Center to the Regional Office. The SIR reported that an incident had occurred on November 19, 2023 at 5:00 PM with Resident 1 (R1) and Staff 1(S1). Facility Administrator, Jerry Abengana, was not notified of the incident until November 29th, 2023. S1 reported to the Administrator that R1 expressed escalated behaviors. S1 attempted to de-escalate R1; however, was not successful, resulting in R1 to continue with escalated behaviors. R1 started crawling, chasing S1, and attempted to hit S1. To avoid being hit, S1 held R1's shoulder to avoid being hit. S1 called for help from another staff member, Staff 2 (S2). S2 witnessed the incident. S1 or S2 did not report the incident until 11/29/23. Administrator placed S1 on leave pending the investigation of the incident and cross reported to Rancho Cordova Police Department, Local Ombudsman, family members, and Alta Regional Center

During today's visit, LPA Valerio interviewed 3 out of 4 staff members, interviewed 1 resident, interviewed outside agencies, conducted facility records review, and obtained facility records for future reference. LPA to share information with the Regional Office and will return to update the Administrator of findings.

Per California Code of Regulations (CCR) - Title 22, no immediate health or safety concerns were observed. An exit interview was held, and a copy of the report was provided to designated staff Elaine Abengana.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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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